[Senate Hearing 115-870]
[From the U.S. Government Publishing Office]




                                                        S. Hrg. 115-870

                 THE FRONT LINES OF THE OPIOID CRISIS:
                       PERSPECTIVES FROM STATES,
                       COMMUNITIES, AND PROVIDERS

=======================================================================

                                HEARING

                                 OF THE

                    COMMITTEE ON HEALTH, EDUCATION,
                          LABOR, AND PENSIONS

                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                                   ON

      EXAMINING THE FRONT LINES OF THE OPIOID CRISIS, FOCUSING ON 
          PERSPECTIVES FROM STATES, COMMUNITIES, AND PROVIDERS

                               __________

                           NOVEMBER 30, 2017

                               __________

 Printed for the use of the Committee on Health, Education, Labor, and 
                                Pensions



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                 U.S. GOVERNMENT PUBLISHING OFFICE

48-380 PDF                WASHINGTON : 2022








          COMMITTEE ON HEALTH, EDUCATION, LABOR, AND PENSIONS

                  LAMAR ALEXANDER, Tennessee, Chairman

MICHAEL B. ENZI, Wyoming	      PATTY MURRAY, Washington
RICHARD BURR, North Carolina	      BERNARD SANDERS (I), Vermont
JOHNNY ISAKSON, Georgia		      ROBERT P. CASEY, JR., Pennsylvania
RAND PAUL, Kentucky		      AL FRANKEN, Minnesota
SUSAN M. COLLINS, Maine		      MICHAEL F. BENNET, Colorado
BILL CASSIDY, M.D., Louisiana	      SHELDON WHITEHOUSE, Rhode Island
TODD YOUNG, Indiana		      TAMMY BALDWIN, Wisconsin
ORRIN G. HATCH, Utah		      CHRISTOPHER S. MURPHY, Connecticut
PAT ROBERTS, Kansas		      ELIZABETH WARREN, Massachusetts
LISA MURKOWSKI, Alaska		      TIM KAINE, Virginia
TIM SCOTT, South Carolina	      MAGGIE WOOD HASSAN, New Hampshire

               David P. Cleary, Republican Staff Director
         Lindsey Ward Seidman, Republican Deputy Staff Director
                 Evan Schatz, Democratic Staff Director
             John Righter, Democratic Deputy Staff Director





                            C O N T E N T S

                              ----------                              

                               STATEMENTS

                      THURSDAY, NOVEMBER 30, 2017

                                                                   Page

                           Committee Members

Alexander, Hon. Lamar, Chairman, Committee on Health, Education, 
  Labor, and Pensions, opening statement.........................     1
Murray, Hon. Patty, Ranking Member, a U.S. Senator from the State 
  of Washington, opening statement submitted for the Record......    36
Kaine, Hon. Tim, a U.S. Senator from the State of Virginia.......     3
Paul, Hon. Rand, a U.S. Senator from the State of Kentucky.......     5
Whitehouse, Hon. Sheldon, a U.S. Senator from the State of Rhode 
  Island.........................................................    38
Baldwin, Hon. Tammy, a U.S. Senator from the State of Wisconsin..    38

                               Witnesses

Abubaker, A. Omar, D.M.D, Ph.D., Professor and S. Elmer Bear 
  Chair, Virginia Commonwealth University School of Dentistry, 
  Richmond, VA...................................................     6
    Prepared statement...........................................     7
    Summary statement............................................     9
Boss, Rebecca, MA, Director, Rhode Island Department of 
  Behavioral Healthcare, Developmental Disabilities and 
  Hospitals, Cranston, RI........................................    10
    Prepared statement...........................................    12
    Summary statement............................................    19
Magermans, Andrea, Managing Director, Wisconsin Prescription Drug 
  Monitoring Program, Wisconsin Department of Regulation and 
  Licensing, Madison, WI.........................................    19
    Prepared statement...........................................    21
    Summary statement............................................    27
Tilley, Hon. John C., Secretary, Kentucky Justice and Public 
  Safety Cabinet, Frankfort, KY..................................    28
    Prepared statement...........................................    30
    Summary statement............................................    31



 
                 THE FRONT LINES OF THE OPIOID CRISIS:
                       PERSPECTIVES FROM STATES,
                       COMMUNITIES, AND PROVIDERS

                              ----------                              


                      Thursday, November 30, 2017

                                       U.S. Senate,
                    Committee on Health, Education, Labor, 
                                              and Pensions,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:04 a.m., in 
room 430, Dirksen Senate Office Building, Hon. Lamar Alexander, 
Chairman of the Committee, presiding.
    Present: Senators Alexander [presiding], Murray, Isakson, 
Paul, Cassidy, Young, Murkowski, Sanders, Casey, Franken, 
Bennet, Whitehouse, Baldwin, Murphy, Warren, Kaine, and Hassan.

                 Opening Statement of Senator Alexander

    The Chairman. Good morning. The Senate Committee on Health, 
Education, Labor, and Pensions will please come to order.
    Today's hearing is the second in a series of bipartisan 
hearings on the opioid crisis. Today we're focused on what is 
happening at the state and local levels to address this crisis 
that has touched families in every state.
    Senator Murray and I will have an opening statement, and 
then our Members of this Committee will introduce the 
witnesses. I will call on Senator Kaine when I have completed 
my opening statement and ask him if he would like to make any 
opening remarks and introduce one of our witnesses. I thank him 
for being here.
    After the witnesses' testimony, Senators will each have 5 
minutes of questions.
    I mentioned to the witnesses that the subject is a subject 
of interest to every single Senator on both sides of the 
political aisle, but we're in the midst of a tax debate today, 
Senators will be coming in and going.
    The toll of the opioid crisis that is ravaging our country 
is staggering.
    One of our witnesses today, Dr. Abubaker, has experienced 
the heartbreak that opioid addiction causes. His son, as a 17-
year-old, was prescribed 90 Vicodin pills for a minor shoulder 
injury. He developed an addiction and overdosed 4 years later 
on a mixture of drugs, including heroin.
    I am grateful that Dr. Abubaker is here to tell his 
family's heartbreaking story and share the work he has done to 
educate other doctors about prescribing opioids.
    As Dr. Abubaker has said, ``People from all walks of life 
have had problems. It has nothing to do with where you live or 
where you came from. You could be the President. You could be 
the son of a doctor.''
    Last month, this Committee held the first in a series of 
hearings this Congress has had on the opioid crisis, a crisis 
that is tearing our communities apart, tearing families apart, 
and posing an enormous challenge to health care providers and 
law enforcement officials.
    That hearing was focused on the federal response to the 
opioid crisis, and today we will hear from those on the front 
lines. Our witnesses represent states, communities, and 
providers who will share what they are doing and what, if any, 
changes are needed to federal law to fight the crisis. These 
witnesses come from four different states. They have personal 
and professional perspectives on the opioid crisis from the 
judicial and public health sectors.
    We hope to hold an additional hearing early next year as we 
build on our work from last Congress, which included passing 
the 21st Century Cures Act, appropriating $1 billion over 2 
years for state grants, and the Comprehensive Addiction and 
Recovery Act, which created new programs to address this 
crisis.
    I mentioned some of the tragic statistics of this crisis at 
our last hearing, but they are worth repeating.
    The amount of opioids prescribed in the U.S. in 2015 was 
enough for every American to be medicated around the clock for 
3 weeks, according to the Centers for Disease Control and 
Prevention.
    Across the country, 91 Americans die every day from an 
opioid overdose.
    In my home State of Tennessee, 1,631 Tennesseans died of a 
drug overdose last year, 12% more than the year before, mostly 
due to an increase in overdoses of synthetic opioids, including 
fentanyl, a pain medication that is 50 to 100 times stronger 
than morphine and can kill with just a small dose.
    It seems that every day there are new studies and 
statistics that further describe the toll of this crisis.
    For example, last week the White House Office of Economic 
Advisers released a report that estimated the opioid crisis 
cost $504 billion in 2015.
    As we talk about this crisis from a state perspective, I 
hope to hear from our witnesses how are different State 
Departments--medical, public health, and judicial systems--
working together in a collaborative way to address this crisis? 
What innovative approaches are states taking to address the 
distinct challenges they face?
    For example, Rhode Island is working to connect individuals 
who overdose with recovery coaches while they receive treatment 
in hospital emergency departments to try to get people into 
treatment and break their cycle of addiction in the long term.
    The Federal Government remains an important partner in the 
opioid crisis. Earlier this month, the President's Commission 
on Combatting Drug Addiction and the Opioid Crisis released 
recommendations, and I hope our witnesses will touch on some of 
those today.
    We also want to know what is being done with the tools and 
resources provided in the CARA Act and in the Cures Act, 
whether these laws are helping make progress, and if not, why 
not.
    This past spring, the Administration began issuing grants 
funded by the Cures Law for states to use in combatting the 
opioid crisis. These totaled $485 million to all 50 states. 
Because each state is facing different challenges in responding 
to the crisis, it is important that states have flexibility in 
how to use the money.
    Tennessee, for example, received $14 million of that money. 
It is using the money to distribute naloxone, a drug that can 
reverse an overdose, and train people how to use it to reduce 
the number of overdose deaths; to expand access to medication-
assisted treatment; and to implement strategies to help reduce 
the number of babies born who experience withdrawal from 
opioids. In the last 10 years, Tennessee has seen a nearly ten 
fold rise in the incidence of babies born addicted to opioids.
    Other states are using the grants from Cures to address 
different needs within their states. For example, Arkansas is 
using its grant to expand access to buprenorphine, a 
medication-assisted treatment.
    Other states are using funds to improve state-run 
prescription drug monitoring programs, the electronic data 
bases that can track controlled substances prescribed by 
doctors and dispensed by pharmacists. That way, doctors can see 
whether a patient has already been prescribed an opioid by 
another doctor across the street.
    I'm eager to hear how these programs are run in your states 
and if there are things that can be done at the federal level 
to help improve coordination and data-sharing at the state 
level.
    Now I would like to call on the Senator from Virginia, 
Senator Kaine, and invite him to make any remarks that he would 
like to make and to introduce our first witness, and then I 
will introduce the others.

                       Statement of Senator Kaine

    Senator Kaine. Thank you, Mr. Chair. I so appreciate the 
opportunity to say some opening words on behalf of my 
colleagues, especially Senator Murray. You will see Senators 
coming in and out today. I have three hearings going right now, 
and there are meetings about tax reform. But you'll see many 
Senators here. This is an important topic.
    I saw a chart once about 2 years ago about the opioid 
problem in the United States. It was unlike any chart I had 
ever seen. I was a mayor and Governor before I came to the 
Senate, and I'm used to looking at charts, and I often look at 
charts that look at various challenges, whether it's low-birth-
weight babies or educational outcomes or percentage of kids in 
juvenile detention facilities. I often look at these charts 
where they rank states 1 to 50, from best to worst.
    Most charts of this kind, the best states are wealthy and 
the worst states are poor. It's kind of sad that you can pretty 
much put up just a list of states from high per-capita income 
to low per-capita income and that's going to tell you where 
they are going to be on the measure of virtually any social 
challenge.
    The opioid chart I saw was completely different, deaths per 
100 or per 1,000 to opioid overdoses. I looked at the best 10 
states in the country, and there were rich states and poor 
states. I looked at the worst 10 states in the country, and 
there were rich states and poor states. This is not a problem 
that respects race or region or socioeconomic status, and in 
that sense it's a very different kind of a challenge than 
virtually any challenge that we deal with on this important 
Committee.
    In Virginia, 1,460 people died of overdoses in 2016, and 
that was an 18% increase from the previous year, 2015, even 
though we were paying more attention.
    We have been riveted upon this problem, with a Governor, 
Governor McAuliffe, having appointed a special task force, 
declaring a public health emergency in 2013 at the urging of 
many of the congressional delegation. But even with this 
intense focus and intention, the number of overdose deaths 
increased. Eighty percent of those were opioids, and of that 
number, 80% of the opioid overdoses were people whose addiction 
began when a doctor wrote them a prescription.
    The increase in the number of deaths in Virginia, as in 
Tennessee, as the Chairman indicated, was largely attributed to 
the flooding of the market with fentanyl, a much higher 
potency, much more dangerous product.
    This is an important hearing to hear what our states are 
doing so that we can, hopefully, together with our FDA, our 
HHS, our other health research agencies, tackle this challenge. 
I think we should try to set a goal as a society to be 
addiction free by 2030, just like we set a goal to be on the 
moon at the end of the decade in the 1960's.
    What we know about the medical aspects of addition, but 
also what we know about potential ways to treat, we could do it 
if we put our minds and especially our resources to it.
    It is my real honor to introduce the first witness today 
who is a personal friend, and it's Dr. Omar Abubaker of 
Richmond. Dr. Abubaker I first came to know because his 
daughter Sarah, who is sitting here in the chamber, worked for 
me when I was Governor, and Sarah's brother Joseph is also 
here, and this is a wonderful family in Virginia that has had a 
horrible story.
    Their youngest son Adam, who I met once when I was in line 
at a local movie theater with Dr. Abubaker, had a minor 
shoulder injury when he was 17 years old playing football, and 
he was prescribed 90 Vicodin for this minor shoulder injury.
    His dad is a doctor. His dad is a dentist. But like many, 
this prescription from an orthopedist seemed like exactly what 
should be done and exactly what should be followed for his son 
to try to deal with his health challenge.
    Instead, that prescription turned into a horrific addiction 
and led to Adam's death.
    Dr. Abubaker is the endowed Chair and Head of the Oral and 
Maxillofacial Surgery Department at Virginia Commonwealth 
University. He is a dentist. He is a Ph.D. After his son's 
death, he has immersed himself in studying addiction issues, 
and also has a certificate in International Addiction Studies 
at a program that VCU has started, together with the University 
of Adelaide in Kings College, London.
    Dr. Abubaker has shared with me as a Ph.D. and a dentist, 
in a profession that often prescribes opioid-based medicines, 
he thought that he knew a lot. But as he's gotten into the 
science of addiction, he realized that even with this extensive 
training he knew very little about the science of addiction and 
about what are the appropriate ways to deal with pain 
management.
    He has made it his mission, based on the painful experience 
of his family, to try to educate first his students--and the 
VCU School of Dentistry is the producer of all the dentists in 
Virginia, virtually--first his students, but then others in 
what are the right ways to deal with pain and what are the 
right ways to prescribe opioids or other medications.
    It's a painful thing that really words can't express the 
pain that Dr. Abubaker's family has gone through, but his 
willingness and his passion and dedication to taking the 
experience and educating others so that other families don't 
have to go through what his family has experienced is something 
I really admire.
    Dr. Abubaker, we really appreciate you being here today and 
enlightening the Committee.
    Senator Alexander will now introduce the other witnesses, 
and then he'll ask you to make your opening statement.
    Thank you, Senator Alexander.
    The Chairman. Thank you, Senator Kaine, for your remarks 
and for the introduction.
    Welcome, Dr. Abubaker.
    I will now ask Senator Paul if he would like to introduce 
Secretary Tilley, and then I will introduce the other two 
witnesses.

                       Statement of Senator Paul

    Senator Paul. It's my pleasure to introduce Secretary John 
Tilley, a great example of how we have a Republican Governor 
and at least a Democrat at one time, and maybe still a 
Democrat, but bipartisan support for an issue that's not really 
a partisan issue to try to fix this.
    I have long been an admirer of Mr. Tilley as far as 
criminal justice reform, as well as his efforts with this. He's 
our Secretary of Kentucky Justice and Public Safety. He's a 
native of Hopkinsville, graduate of the University of Kentucky 
and Chase College of Law in northern Kentucky, a former 
prosecutor known for his work in criminal justice reform. He 
also served five terms in the State Legislature.
    We're glad to have you here and we look forward to your 
testimony.
    The Chairman. Thank you, Senator Paul. Welcome, Secretary 
Tilley.
    Senator Whitehouse and Senator Baldwin will be here before 
long, and they'll want to say something about our other two 
witnesses. But to give them a brief introduction, Rebecca Boss 
is Director of the Rhode Island Department of Behavioral 
Healthcare, with more than 25 years of experience in addiction 
treatment.
    Welcome, Ms. Boss.
    Then Andrea Magermans is the Acting Managing Director of 
the Wisconsin Prescription Drug Monitoring Program, who has 
worked on all aspects of the operations of Wisconsin's Drug 
Monitoring Program and helped oversee the development and the 
launch of the Wisconsin Enhanced Prescription Drug Monitoring 
Program in 2017.
    Welcome to you.
    We now begin with Dr. Abubaker and ask each of you to 
summarize your remarks in about 5 minutes each, and that will 
leave time for Senators to ask questions and to have a 
conversation with you.
    Dr. Abubaker, welcome.

                 STATEMENT OF A. OMAR ABUBAKER

    Dr. Abubaker. Thank you, Chairman Alexander. Thank you, 
Senator Kaine, for the kind words. Thank you, other 
distinguished Members of the Committee. It's an honor to appear 
before you today.
    Before today is over, as Chairman Alexander mentioned, 
about 91 people will die from opioid overdose. In fact, 
approximately 175 Americans will die from all drugs overdose, 
91 from opioids. By the end of this year, the death toll from 
all drugs overdose in this country will be about 64,000. That 
would fill the entire seating assignment for the former RFK 
Stadium.
    My youngest son, Adam, was one of those people who died 
from an opioid overdose. He died from drug overdose early in 
the morning of Saturday, September 27th, 2014. He was 21 years 
old. Adam did not choose heroin addiction. He volunteered as a 
firefighter while he was in high school for 3 years and was 
studying to be an EMT at the time of his death. He was 
altruistic until the end, donating his organs to save four 
lives.
    It's difficult to comprehend that a high school football 
injury and a medical device to take one to two Vicodin tablets 
every four to 6 hours, as needed, for pain led him to addiction 
and death. A thousand other parents who have lost their 
children to opioids understand my heartbreak. But I'm also a 
practicing oral surgeon and an educator, so my pain is 
magnified because my profession shares some of that burden.
    Since my son's death 3 years ago, hundreds of thousands of 
other parents in this country have had the same dreadful phone 
call. In Adam's memory, I have become a foot soldier in the war 
on addictions, teaching about the proper drug use at my 
university and traveling the Commonwealth of Virginia to 
advocate for responsible prescribing practices.
    In my lectures, I explain to dentists and others the harms 
of addiction and over-prescribing. My goal is that each student 
and practitioner leaving my class will be less inclined to 
prescribe excessive opioids, perhaps protecting one more son or 
daughter against the harm of narcotics. That's my effort, and 
that is my colleagues at Virginia Commonwealth and VCU Medical 
Center.
    In Virginia this year, the legislators and the Governor 
signed laws that were passed that have led to several 
regulations. Just a few of those regulations are limiting the 
number of opioid tablets prescribed for acute pain, using 
prescription monitoring program, and increasing the 
availability of naloxone and training for naloxone use. This 
effort has resulted in a marked decrease in the number of 
opioid prescriptions since these regulations were enacted in 
Virginia, and I can see on the ground that students, residents, 
and practitioners have changed their prescribing practices.
    Nothing I have done or will do will bring my son back. It 
is too late for Adam and others like him. However, we need to 
do everything we can to see that such tragedy does not 
continue. We need similar or even more legislative steps across 
the country to ensure this happens.
    Despite the colossal human cost of the opioid crisis, this 
is only the tip of the iceberg in terms of human and financial 
cost of addictions as a disease. The American Medical 
Association and the American Society of Addiction Medicine have 
designated addiction as an organic brain disease. Yet, teaching 
about it in most health care professional curricula and access 
to treatment for those affected is far from what the AMA and 
the SA intended it to be. Moreover, the stigma associated with 
addictions deter people who are affected from seeking treatment 
in the first place because of the shame associated with it. 
Many may not be able to access treatment even when they seek 
it.
    I hope your Committee will keep this in mind as you go 
through this hearing. I hope you also do not take your eye off 
the ultimate goal that needs to be attained. Please do not 
confuse winning the battle against the opioids with winning the 
war on addiction, which should be our ultimate goal. We need to 
assure funding and coverage for addiction treatment and for 
mental illness across the country through state, federal, and 
commercial insurance carriers.
    We also need to change our entire educational system so 
that we will see addiction for what it is, a disease of the 
brain. Opioids are only the decoy, but the real foe is 
addiction. We need to combat the opioid epidemic so we save our 
children. But we also need to regard and treat addiction as a 
disease to protect our grandchildren from what may come in the 
next 10, 15, or 20 years from now.
    Again, thank you very much for your invitation, and I'm 
privileged to be here. Thank you.
    [The prepared statement of Dr. Abubaker follows:]

                                ------                                

                 Prepared Statement of A. Omar Abubaker
    Before today is over, approximately 175 people will die from a drug 
overdose in our country, and over the next 3 weeks more than 3,500 will 
die from the same thing. That is more than all the people who died from 
the September 11 terrorist attack.
    My youngest son, Adam, overdosed early in the morning of Sept. 27, 
2014, on a mixture of heroin and benzodiazepines. He died in the 
intensive care unit of a local hospital four days later. He was 21.
    Adam didn't choose heroin addiction. He volunteered as a 
firefighter while in high school and was studying to be an EMT when he 
died. He was altruistic until the end, donating his organs to save four 
lives.
    Since my son's death 3 years ago, more than 165,000 other parents 
in this country have experienced the same agony. Carrying his suffering 
and tragic death with me, I have been teaching at my university and 
traveling the Commonwealth of Virginia talking about the opioid 
epidemic, pain management and addiction to anybody who will listen. My 
goal is that each student and practitioner who leaves my class will be 
less inclined to prescribe excessive opioids, perhaps guarding one more 
son or daughter against the harm of narcotics. Nothing I have done, or 
will ever do, will bring my son back. It is too late for Adam and for 
another 165,000 like him, but it may not be too late for other fathers 
and mothers. I am doing my part to see to it that it is not too late 
for these parents. I am praying that all Americans will do their part, 
regardless of their political position or role, so that my efforts will 
be worth while.
    In Virginia, the opioid crisis was declared a public health 
emergency in 2016. In the spring of 2017, the following became 
regulations to combat the epidemic:

    On the prevention front: The Boards of Medicine and Dentistry 
enacted regulations (effective May, 2017) to limit opioid prescription 
for acute pain to 7 days (14 days for post-surgical pain). The Medical 
regulations also drew from the CDC guidelines to require best practices 
for the prescribing of opioids for chronic pain (e.g., prescribing of 
naloxone if >90 MME, avoiding concomitant opioid and benzodiazepine 
prescribing, requiring periodic urine screening, and checking the 
Prescription Monitoring Program (PMP) when prescribing opioids for >7 
days. Virginia's PMP can identify outlier prescribing or dispensing and 
refer to Department of Health Professions enforcement for 
investigation. Prescribers are also now required to complete 2 
continuing education credits on pain management and opioids as a 
requirement for licensure renewal.
    Since May, more than 48 prescriber education sessions were held to 
make prescribers aware of the new regulations. As a result of these 
efforts, there has been a 30% decrease in the number of pills 
prescribed in the Commonwealth. On the treatment front, Virginia's new 
law includes immunity for naloxone administration, and allows 
dispensing of naloxone after state-sanctioned trainings. As a result, 
more than 11,000 doses of naloxone have been made available. The new 
laws also allow for needle exchange in health districts, in 
coordination with local governments. Further, the Virginia Addiction 
and Recovery Treatment Services program, a Medicaid waiver to allow 
increased reimbursement for the full range of treatment services, has 
dramatically increased the number of treatment providers and resources 
in Virginia, and is being recognized nationally. Virginia's Department 
of Health and Department of Medical Assistance Services (DMAS) worked 
extensively in 2016 to increase the number of physicians who are 
waivered to prescribe buprenorphine for addiction (Medication-Assisted 
Treatment (MAT)). This resulted in increased treatment services with 
better quality. In addition, our Department of Medical Assistance 
Services, our Medicaid, pulled together insurers, health systems, and 
governmental units to develop ARTS (Addiction and Recovery Treatment 
Services), a new Medicaid benefit designed to increase treatment for 
addiction.
    At my institution, Virginia Commonwealth University and VCU Health, 
we have been relentless in advancing these issues. Also, at VCU, a 
curriculum on the topics of opioids, pain management and addiction has 
been initiated. In addition, VCU faculty established a clinic for 
treatment of addiction treatment and several measures were adopted in 
developing policies and guidelines for pain management and opioid 
prescribing for both inpatients and outpatients at the VCU Health 
hospitals and clinics.
    The initial data show that these legislations and policies are 
working. In addition, as I interact with students, residents and 
faculty at the university and medical center, and as I travel around 
the Commonwealth and talk to dentists, I see a willingness to learn and 
change practices by all.
    These attempts to change by legislators, educators and doctors in 
Virginia can even be more effective if the neighboring states would 
adopt similar legislations and guidelines or opioid prescribing and for 
educational reforms. In fact, the variation among states makes 
individual efforts less effective. If some of these regulations were 
federal, and if there are federal mandates for educational changes on 
opioid prescribing, pain management and addiction, we will have even 
more impact on curbing the epidemic. Encouraging and supporting states 
to provide reimbursement for treatment of addiction (just as coverage 
of other diseases), and expanding resources and funding training 
programs (residency or fellows), we can speed up reining in the 
epidemic, and save lives.
    The heartbreaking current trail of deaths from drug overdose is 
only the tip of the iceberg regarding the current number of deaths from 
the disease of addiction. The American Medical Association and American 
Society for Addiction Medicine have designated addiction as an organic 
brain disease, yet teaching and treating it as such by most Some The 
stigma associated with addiction deters people who are affected from 
seeking treatment because of the shame. Some may not be able to access 
treatment even when they seek it.
    I worry that we will not address the root of the current opioid 
epidemic, which are addiction and mental illness, as the underlying 
reasons for all drug epidemics we have been through and will face in 
the future. If we do not address the foundations of these epidemics, I 
fear that another drug epidemic will emerge years from now and another 
generation of Americans (maybe our grandchildren) will be facing a drug 
crisis of different kind. We had better not let that happen. With the 
knowledge we have now about brain functions and how addiction affects 
it, to let future generations of Americans be affected by a similar 
crisis in the future would be an historical abdication of our 
responsibility to do good by our country.
    Finally, on behalf of the parents and families who lost loved ones, 
I am looking to you to act boldly. We need federal reform of all of our 
educational systems to include scientific facts about addiction, drugs 
and all substances of abuse. We need to prevent the harmful effects of 
such exposure through education and by identifying those at risk and 
interrupting the disease at its earliest stages. We are also looking to 
you to allocate funds in the Comprehensive Addiction and Recovery Act 
and in the 21st Century Act coverage, not only for treatment of all 
forms of addiction and its underlying mental illness, but also to 
extend coverage for screening of those at risk for addiction, brief 
interventions and referral for treatment (SBIRT) of those affected. Let 
us make ``SBIRT'' the new 5th vital sign in our emergency rooms, doctor 
offices and everywhere patients interface with the health care system. 
These are historical times in our country's health system, and it can 
easily be compared to a plague such as with tuberculosis and AIDS in 
our time. I hope you leave your mark on history by acting boldly so 
that the loss of our children will not be in vain.
    Thank you for giving me the honor and opportunity to speak before 
you and I thank you for what you are doing on this front.

                                 ______
                                 
                [summary statement of a. omar abubaker]
    Before today is over, approximately 175 Americans will die from a 
drug overdose, and over the next 3 weeks, more than 3,500 will die from 
the same thing. That is more than all the people who died from 
September 11 terrorist attack. My youngest son Adam was one of these 
people who died from a drug overdose early in the morning of Sept. 27, 
2014. He was 21.

    Adam didn't choose heroin addiction. He volunteered as a 
firefighter while in high school and was studying to be an EMT when he 
died. He was altruistic until the end, donating his organs to save four 
lives. It is difficult to comprehend that a high school football injury 
and the medical advice to take ``one or two Vicodin tablets every four 
to 6 hours as needed for pain'' led him to addiction and death.

    Thousands of parents who have lost children to opioids understand 
my heartbreak, but I am also a practicing oral and facial surgeon and 
an educator so my pain is magnified because my profession shares some 
of that burden.

    Since my son's death 3 years ago, hundreds of thousands of other 
parents in this country have had the same dreadful phone call. Carrying 
his life suffering and tragic death with me, I have become a foot 
soldier, teaching about proper drug use at my university and traveling 
the Commonwealth of Virginia to advocate for responsible prescribing 
practices. In my lectures, I explain to dentists and others the harms 
of addiction and over-prescribing opioids. My goal is that each student 
and practitioner leaving my class will be less inclined to prescribe 
excessive opioids, perhaps protecting one more son or daughter against 
the harm of narcotics. That is my effort and that of others in our 
medical center.

    In Virginia, several laws were passed that have led to regulations 
for prescribers. These regulations include limiting the number of 
tablets prescribed for acute pain, using prescription monitoring 
programs, increasing availability of naloxone, increasing the number of 
physicians who are waivered to prescribe Medication-Assisted Treatment 
(MAT) and recommendations for increasing curricular competencies in 
pain management, opioid prescribing, and addiction in Virginia's health 
care professional schools.

    These efforts have resulted in a marked decrease in the number of 
opioids prescribed since the regulations were enacted and I can see the 
change in the students', residents', and practitioners' prescribing 
practices.

    Nothing I have done, or will do, will bring my son back. It is too 
late for Adam and others like him. However, we need to do everything we 
can to see that such tragedies do not continue! We need similar or even 
more legislative steps across the country to assure this happens, 
despite the colossal high human cost of the opioid crisis, this burden 
is only the tip of the iceberg in terms of the human and financial cost 
of addiction as a disease. The American Medical Association and 
American Society for Addiction Medicine have designated addiction as an 
organic brain disease; yet, teaching about it in most medical 
curricula, and access to treatment for those affected, is far from what 
the AMA and the ASA intended it to be. Moreover, the stigma associated 
to addiction deters people who are affected from seeking treatment 
because of the shame. Some may not be able to access treatment even 
when they seek it.

    I hope your Committee will keep this in mind as you go through 
these hearings. I also hope you do not take your eye off the ultimate 
goal that needs to be attained. Please ensure that when we win the 
battle against the opioid epidemic we do not mistake it for winning the 
war on addiction, which should be our ultimate goal. We need to assure 
coverage for addiction treatment and for mental illness across the 
country through state, federal and commercial insurance carriers.

    We also need changes in our entire educational system so that we 
all see addiction for what it is--a disease of the brain. Opioids are 
the decoy, but the real foe is addiction. We need to combat the opioid 
epidemic to save our children, but we also need to regard and treat 
addiction as a disease to protect our grandchildren from what may come 
next.

    Thank you for the giving me the honor and opportunity to testify.

                                 ______
                                 
    The Chairman. Thank you, Dr. Abubaker, and thank you for 
your courage and advocacy and for being here today.
    Ms. Boss, welcome.

                   STATEMENT OF REBECCA BOSS

    Ms. Boss. Thank you. Chairman Alexander and distinguished 
Committee Members, in Rhode Island I am responsible for the 
development and oversight of the state's Substance Use 
Disorder, Treatment Prevention and Recovery system. I am also a 
Board Member of the National Association of the State Alcohol 
and Drug Abuse Directors.
    Thank you for allowing me to share Rhode Island's work in 
combatting the opioid crisis, an effort that has been proposed 
as a national model. Our strategies to address this epidemic 
are clearly outlined on our website, preventoverdoseri.org. 
It's important that our efforts are data driven and publicly 
transparent.
    First and foremost, I would like to thank Congress for the 
federal funding so critical to states through the Department of 
HHS agencies, specifically SAMHSA, CDC and HRSA. Additionally, 
we are appreciative of the action Congress took passing the 
CARA and the 21st Century Cures Act.
    Addiction and overdose are claiming lives, destroying 
families, and undermining the quality of life across Rhode 
Island. Over the last 5 years, our small state has lost more 
than 1,200 people to overdose. In 2015, soon after her 
election, Rhode Island Governor Gina Raimondo recognized the 
need for the state to develop a comprehensive strategy to 
reverse this trend. She established the Governor's Overdose 
Prevention and Intervention Task Force, Co-Chaired by myself 
and the director of the Department of Health. This 
multidisciplinary task force is the center of our efforts and 
is composed of an array of stakeholders and experts which 
represent the kind of partnerships necessary for progress.
    We have made significant strides in all four areas of our 
strategic plan: prevention, rescue, treatment, and, as you 
mentioned, Chairman, recovery. This week, Rhode Island will 
announce a 10 percent reduction in overdose rates in 2017. We 
are cautious to be overly optimistic in the face of a dynamic 
epidemic but can't help but believe we are beginning to see the 
results of our efforts.
    The battle is far from over. We need to press on. But we 
see a glimmer of hope.
    Access to treatment is the cornerstone of Rhode Island's 
efforts, and we promote that every door is the right door. 
Evidence indicates that all three forms of medication-assisted 
treatment have life-improving effects on people with opioid use 
disorders. It reduced the risk of death, relapse, 
incarceration, and greatly improves quality of life.
    Federal funding through grants and the Cures Act have 
helped Rhode Island promote this treatment through the creation 
of Centers of Excellence, supporting MAT and primary care 
practices, and supporting psychiatric services for co-occurring 
disorders.
    With higher vulnerability for overdose, the population of 
the Department of Corrections is a focus for intervention. With 
every door being the right door, Rhode Island provides MAT 
through our combined prison and jail system. The Governor 
committed $2 million of state funding in Fiscal Years 2017 and 
2018 to this program. All people entering corrections are 
screened for opioid use disorders and, if appropriate, are 
continued or initiated on MAT. Inmates nearing release are 
offered MAT if clinically appropriate.
    Now, Rhode Island has successfully implemented a 
comprehensive MAT program in the correctional system, with over 
300 inmates receiving medications for addiction treatment every 
month. Connection to care in the community post-release is 75 
percent. Preliminary findings suggest substantial reductions in 
overdose mortality for people with recent incarceration. This 
is a remarkable achievement considering the high risk posed by 
fentanyl circulating in our communities.
    The revision of data waiver requirements through CARA has 
had a positive impact on our provider capacity. Data waiver 
training incorporated into the curriculum of the medical school 
at Brown University means that new graduates are eligible to 
join fellow physicians in treatment of opioid use disorders 
using evidence-based medicine. Rhode Island now has 20 new data 
waiver prescribers that are mid-level practitioners. At least 
one of Rhode Island's physician assistant programs is offering 
clinical rotations through our Center of Excellence.
    In Rhode Island, we rely heavily on data to inform our 
processes. We have implemented a multidisciplinary overdose 
death evaluation team which seeks to gain insight into emerging 
trends, identify gaps or opportunities, and inform the 
distribution of local funding to communities. The Surveillance 
Response and Intervention Workgroup reviews updated overdose 
data on a weekly basis to alert communities when activity 
exceeds baseline. The community overdose engagement program 
calls for task force members to engage with communities in 
developing individualized responses when overdose activity 
repeatedly exceeds thresholds.
    Before concluding, I humbly submit a few recommendations.
    Creation of federal regulations and/or funding requirements 
that explicitly prohibit discrimination against MAT and the 
individuals who receive it. Any federal initiative should 
include the involvement of the State Alcohol and Drug agencies. 
Our staffs have the expertise and authority that can help chart 
the right course.
    Increasing funds through the state substance abuse, 
prevention and treatment block grant issued through SAMHSA. The 
SAPT block grant offers a means to distribute funds effectively 
and efficiently and provides opportunity for states to 
individualize interventions.
    Eliminate the prohibition for the use of federal medicaid 
funds to treat incarcerated adults. Rhode Island's experience 
demonstrates how a thoughtful approach can reduce overdose and 
relapse, encourage recovery, and potentially impact recidivism. 
State general revenue dollars cannot be expected to sustain 
this effort.
    For Rhode Island, the continued availability of Medicaid 
expansion and affordable health insurance to support treatment 
access is essential to our success, and continued funding 
through CARA and the Cures Act.
    Thank you for this opportunity, and I look forward to 
questions.
    [The prepared statement of Ms. Boss follows:]

                                ------                                

                 Prepared Statement of Rebecca L. Boss
    Chairman Alexander, Ranking Member Murray and Distinguished 
Committee Members, my name is Rebecca Boss. I am the Director of the 
Department of Behavioral Healthcare, Developmental Disabilities & 
Hospitals (BHDDH) and lead the development and oversight of the state's 
substance use disorder treatment, prevention and recovery service 
system.

    It is a privilege to serve my home State of Rhode Island under the 
leadership of Governor Gina Raimondo and Secretary of Health and Human 
Services Eric Beane.

    With more than 25 years' experience in both state government and 
the provider community in substance use disorders, and as a Board 
Member of the National Association of State Alcohol and Drug Abuse 
Directors, also known as NASADAD, I feel that I am uniquely positioned 
to testify on this crucial matter.

    Thank you for the invitation to appear before you to allow me to 
give you Rhode Island's perspective on the Front Lines of the Opioid 
Crisis. First and foremost, I wish to thank Congress for the federal 
funding that is essential to state agencies like BHDDH that comes to us 
through agencies of the Department of Health & Human Services, 
specifically SAMHSA, CDC and HRSA.

    Furthermore, we are very appreciative of the action Congress took 
last year passing the 21st Century Cures Act with $1 billion to help 
support prevention, treatment and recovery throughout the country. We 
are grateful for the funds which are enabling us to carry out our much-
needed work with Congressional support. As a note, we are supportive of 
the revisions to the Cures Act sponsored by Senator Jeanne Shaheen, 
which allow funds to flow to the states with ``a prevalence of opioid 
use disorders, and a mortality rate associated with opioid use 
disorders.'' This change will allow the hardest hit states to move 
quickly and with flexibility.

    Addiction and overdose are claiming lives, destroying families, and 
undermining the quality of life across Rhode Island. For over a decade, 
opioid dependence and accidental drug overdose have been growing 
problems across the United States, and Rhode Island has been one of the 
hardest hit. Over the last 5 years our small state has lost more than 
1,200 people to drug overdoses, coming from every community in the 
state. That is the equivalent of three Boeing 747's crashing with full 
passenger loads--lives needlessly lost.

    Our work must be focused on saving lives. RI Governor Gina Raimondo 
recognized this and soon after her election in 2015, she knew the state 
needed a focused, statewide strategy to evaluate, prevent, and 
successfully intervene to reverse the overdose trends. She realized the 
scope of the problem had underlying issues, factors and consequence, we 
needed a new approach to combat this epidemic. Clearly, something 
different had to be created and implemented.

    In order to develop a far-reaching approach, the Governor 
established the Governor's Overdose Prevention and Intervention Task 
Force naming the Directors of BHDDH and the Department of Health (DOH) 
as Co-Chairs. The Task Force included stakeholders and experts in 
fields ranging from public health and law enforcement to healthcare, 
community-based support services, insurance, academia, business, 
government and more. A Strategic Plan to Address Opioid Addiction and 
Overdose was created which recommended specific, evidence-based 
strategies in four areas: prevention, rescue, treatment and recovery. 
The plan was data-driven plan and with the help of Brown University, a 
web site was created (www.preventoverdoseri.org) where all efforts are 
tracked in a public and transparent fashion.

    The multi-disciplinary composition of the Task Force became its 
distinguishing factor. The Task Force soon became the center of all 
opioid overdose prevention and intervention activities in the state. 
The perspectives of various individual Members brought cross-learning 
to the sectors around the table. Committees were formed in the four 
areas of Prevention, Rescue, Treatment and Recovery and everyone went 
to work implementing the strategic plan.

    Within the four areas of the strategic plan, much was accomplished 
in 2016 and thus far in 2017. Individual communities; substance use 
treatment, prevention and recovery providers; and law enforcement 
officials created many new initiatives. Legislation was passed. 
Hospitals and emergency department discharge standards were 
implemented. All of this work originated from the Task Force.

    Some the initiatives included:

PREVENTION
    Safer Prescribing: To achieve safer opioid prescribing, it is 
important to weigh the benefits of medication access for patients 
living with acute and chronic pain with those of the risks of 
diversion, addiction, overdose, and premature death. Unsafe 
combinations of prescribed medications are linked to addiction and many 
overdoses are preventable.

    The key strategy to reduce dangerous prescribing is to use the 
Prescription Drug Monitoring Program (PDMP) and system-level efforts to 
reduce co-prescription of benzodiazepines with opioids (for pain or 
opioid use disorder). Before DOH launched its Prescription Drug 
Monitoring Program Enrollment Enforcement Plan in 2016, more than 30 
percent of Rhode Island prescribers had failed to enroll in the PDMP, 
and fewer than 40 percent were using it. As of July 2016, legislation 
had passed that all such practitioners shall be automatically 
registered with the Prescription Drug Monitoring Program maintained by 
the Department of Health. As of today, 100 percent of practitioners are 
enrolled. The state continues to monitor use of the PDMP by prescribers 
as well as sending prescriber profiles to practitioners, and providing 
academic detailing-or one-on-one office visits-to promote safer opioid 
prescribing behaviors.

    Additionally, DOH Director, Dr. Alexander-Scott co-led a successful 
national petition drive calling on the FDA to require ``black box'' 
labels on opioids and benzodiazepines warning that concurrent use of 
these medications increases the risk of fatal opioid overdose.

    Reducing the Supply of Prescribed Opiates (Rx): Rhode Island has 
developed regulations that limit most opioid dosing for acute pain 
management to a contained period of time (with exceptions for 
specifically determined patients) and supports existing hospital policy 
to restrict opioid prescriptions from emergency rooms to 3 days or 
less.

    The promotion of non-opioid therapies for chronic pain, such as 
chiropractic services, massage therapy, physical therapy, and 
acupuncture as important alternatives to opioid pain relief is another 
successful effort in Rhode Island. Access to comprehensive health care 
coverage, including Medicaid, is a crucial component of these non-
opioid alternatives.

RESCUE
    Naloxone as Standard of Care: Naloxone saves lives by reversing the 
severe respiratory depression caused by opioids. Its use by lay people 
trained to identify and respond to overdose has been linked to 
reductions in overdose death rates. People who use opioids are at 
greatest risk of overdose, and are motivated to protect themselves and 
others around them to save a life with naloxone. Law enforcement being 
equipped with naloxone is critical in the fight against opioid 
overdoses. In fact, in Rhode Island two police departments (East 
Providence and North Providence) have offered to purchase naloxone for 
those departments who may not have the funds to purchase it themselves. 
Further, Rhode Island has promulgated regulations requiring all 
inpatient substance use disorder providers to offer naloxone to at-risk 
clients, Emergency Departments are dispensing naloxone to individuals 
who have overdosed, peers distribute on the street, and inmates with 
substance use disorders are given naloxone upon release. Fortunately, 
Medicaid and commercial insurances cover Naloxone through pharmacies in 
RI which allows BHDDH to use other federal funds for additional 
prevention and intervention activities. Furthermore, state law mandates 
insurance to cover at least one generic form of naloxone, including 
naloxone that may be used on a so-called ``third party'': a family 
member or friend whose overdose could be reversed by use of naloxone. 
Rhode Island has some of the highest naloxone distribution per capita 
in the country, and achieving this statistic is an evidence based 
approach: public health impact is greatest when the number of naloxone 
kits distributed is greater than 20 times the number of annual overdose 
deaths, a target that Rhode Island nearly reached in 2016 (target: 
6,720, dispensed 6,387 kits) and is on track to exceed in 2017.
TREATMENT
    Medication Assisted Treatment: Evidence indicates that medication-
assisted treatment (methadone, buprenorphine or depot naltrexone* 
injection) has profound, life-improving effects on people with an 
opioid use disorder. It reduces their risk of death, relapse, chance of 
going to prison, and greatly improves their quality of life. As a 
result, the cornerstone of the Strategic Plan is increasing access to 
MAT for individuals in need. The Strategic Plan called for the 
development of Centers of Excellence to meet that need. These COEs are 
described more fully in sections below.

    Rhode Island supports a model of shared decision making between the 
individual and their provider. We support the use of FDA-approved 
medications for the treatment of opioid use disorder including 
methadone, buprenorphine products, and injectable naltrexone, always in 
the context of comprehensive clinical and recovery support services. 
These supports vary based on patient need, but include drug and alcohol 
counseling, screening and treatment of co-occurring mental and physical 
health issues, checking of the state prescription drug monitoring data 
base, toxicology screening, individual and group therapies, peer 
support services, vocational and educational assistance.

    As part of the strategic plan implementation, Rhode Island offers 
medication-assisted treatment through the combined prison and jail at 
the Department of Corrections. Governor Raimondo committed $2 million 
in the fiscal year 2017 and fiscal year 2018 for medication for 
addiction treatment (MAT) in the state prison system. All people 
entering the system are screened for opioid use disorder. Individuals 
who are awaiting trial are no longer withdrawn from MAT, and those who 
are opioid dependent and not in treatment are able to be inducted on 
whichever medication is most appropriate. Sentenced individuals with 
histories of opioid use disorder are at a significantly increased risk 
of overdose upon release, so these individuals are also being offered 
induction on MAT with linkage to care in the community.

    With higher vulnerability for overdose, the population of our 
Department of Corrections needed a particular focus for intervention. 
Now, Rhode Island has a successful implementation of a comprehensive 
MAT program in the state correctional system, with over 300 inmates 
receiving medications for addiction treatment every month. The 
connection to care in the community, post release is 75 percent. 
Finally, preliminary findings suggest that there are substantial 
reductions in overdose mortality for people with recent incarceration. 
This was an expected outcome, given that dozens of studies indicate 
that MAT cuts risk of overdose mortality by 50 percent or more. Still, 
it is remarkable to achieve such enormous impact despite the 
extraordinarily high risk posed by fentanyl circulating in our 
communities.

    Emergency Department Standards: Leadership from hospitals and 
emergency departments throughout Rhode Island joined Governor 
Raimondo's Overdose Prevention and Intervention Task Force. RI has 
released a first-in-the-nation set of statewide guidelines to save 
lives by ensuring consistent, comprehensive care for opioid-use 
disorder in emergency and hospital settings. Released in March 2017, 
the standards established a common foundation for treating opioid-use 
disorder and overdose in Rhode Island hospitals and emergency 
departments. The standards establish a three-level system of 
categorization that defines each hospital and emergency department's 
current capacity to treat opioid-use disorder. All emergency 
departments and hospitals in Rhode Island will be required to meet the 
criteria for Level 3 facilities, or what we collectively feel are the 
essential components of providing humane and consistent care for people 
with opioid use disorder treated in Rhode Island. Currently, RI's 
hospitals are certified as:

 
----------------------------------------------------------------------------------------------------------------
                     Care New England                                          Providence VA
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                                                        LevIn Process-Certified
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                                                        Lev.....................................................
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                                            Charter Care   South County Hospital
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                                                        LevLevel 3-Certified
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                                                        LanWesterly Hospital
----------------------------------------------------------------------------------------------------------------
                                              In process   In process
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                                                        Lifespan
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                                                        Lev   1-Certified
----------------------------------------------------------------------------------------------------------------


RECOVERY
    Recovery Coaches in Emergency Departments (AnchorED): In May of 
2014, Rhode Island started a pilot program using recovery coaches to 
respond to overdose survivors while they were receiving treatment in 
hospital Emergency Departments. On-call coaches respond to overdose 
survivors and offer support, referrals, resources, family support and 
training on naloxone. This success of this pilot project supported its 
expansion to be offered statewide twenty-four hours per day, 7 days per 
week. These coaches have had great success at engaging clients with an 
85 percent follow up rate with treatment and/or recovery support 
services. This service has provided the state with a wealth of 
information on the experience of individuals with the healthcare system 
as well as the addiction treatment system. While engaging with recovery 
coaches at a crucial point in their addiction, many individuals make 
the decision that they are ready for treatment--seeing the hope of 
recovery through shared experience and recognizing their desperate 
state makes people ready for change.

    Anchor MORE: The success of AnchorED spurned the development of 
AnchorMORE, recognizing that successful consumer engagement does not 
have to wait for an individual to show up at an ED with an overdose. 
The Anchor MORE is a community outreach program, placing recovery 
coaches on the streets to connect with and engage individuals. Anchor 
MORE currently dispatches these teams of recovery coaches to areas in 
which individuals are using substances in public places. Anchor MORE 
teams are also proactively dispatched to certain areas in the state by 
looking at overdose data and emergency services pick-up data. Both 
programs connect individuals with recovery coaches--trained peers with 
lived experience of addiction. Recovery coaches stay actively engaged 
with individuals after an encounter and connect them to treatment and 
recovery support services.

    Recovery Coaches in the Department of Corrections: The RI 
Department of Health has a contract with Anchor Recovery to provide 
peer recovery coaches to inmates prior to release from the Department 
Corrections, continuing this connection post release. The Anchor 
Recovery Center offers a ``Welcome Home'' group to those who 
participate in this program, maintaining crucial positive support at a 
critical time.

THE IMPACT OF FEDERAL PROGRAMS, POLICIES AND FUNDING
    Revision of Data Waiver Requirements through CARA: Rhode Island is 
leading the way with the training of medical students, the first of its 
kind in the country. The 2018 Class of the Warren Alpert Medical School 
of Brown University, which will graduate next May, will be the first 
class to participate in a new program to complete the training 
necessary to qualify for a Drug Abuse Treatment Act of 2000 (DATA 2000) 
waiver prior to graduation. Once the new graduates receive their full 
medical license and DEA registration, they can apply for the DATA 2000 
waiver and join fellow physicians in the treatment of opioid use 
disorders using evidence based medicine.

    Rhode Island has more than 350 Data-waivered providers, allowing 
for the treatment of up to 24,735 patients. RI has 20 new data waivered 
prescribers that are mid-level practitioners. At least one of RI's 
Physician Assistant programs is offering clinical rotations through 
RI's Centers of Excellence for treatment of opioid use disorders.

    Medication Assisted Treatment--Prescription Drug and Opioid 
Addiction (MAT-PDOA) Program: This grant program has enabled RI to 
create and fund Centers of Excellence (COE) for Opioid Use Disorders. 
Centers of Excellence are the cornerstone of Governor Raimondo's Action 
Plan, which was created by the Governor's Overdose Prevention and 
Intervention Task Force.

    COEs provide a means of rapid access to treatment for opioid use 
disorder, provide comprehensive services and work collaboratively with 
community providers of ongoing treatment for the opioid use disorder 
once stabilized in the Center of Excellence. This model also provides 
additional support to community providers-be they physicians or other 
allied providers, or community treatment programs that may not be 
equipped to assist a person who experiences relapse to opioid use by 
re-admitting the person to the Center for any additional stabilization 
needed. These Centers also serve to assist with the workforce 
development needs of our state in that these centers provide practical 
educational experiences in opioid use disorder treatment to community 
providers and trainees alike. Centers of Excellence are funded through 
private third party insurers as well as Medicaid. With Medicaid 
expansion, many more people are able to access Medication Assisted 
Treatment for opioid addiction. Currently, there are nine operating 
Centers of Excellence in Rhode Island. The newest COE to open is on the 
campus of Butler Hospital in 
Providence and is open 24/7.

    State Targeted Response (STR) Grant: The STR has been very 
impactful in Rhode Island. These funds allowed the state to supplement 
existing opioid program activities and supports a comprehensive 
response to the opioid epidemic through integrated planning and 
monitoring.

    Specifically, this one grant:

         Provides five nurse care managers to five high-risk 
        communities to increase the use of MAT in large primary care 
        practices ($500,000)

         Provides psychiatry services to the Centers of 
        Excellence and the Opioid Treatment Programs to address co-
        occurring disorders in an under served population ($500,000)

         Implements the Recovery Housing Pilot with 40 level 
        three beds for those at risk ($536,825)

         Provides OTPs with fentanyl testing kits for regular 
        screenings to enhance targeted interventions ($60,000)

         Incentivizes practitioners to become DATA waivered 
        ($75,000)

         Funds local community implementation of evidence based 
        prevention strategies to five at-risk communities ($240,066)

         Provides naloxone kits to the Department of 
        Corrections and to Rhode Island's Mobile Outreach and Education 
        Program for distribution in targeted at-risk locations 
        ($99,975)

         Provides added funding to the state's awareness 
        campaign for opioid use disorders ($50,000)

    National Institute on Drug Abuse: Grant awarded to Rhode Island 
Hospital, working in partnership with the state to develop pharmacy-
based MAT provision for maintenance with buprenorphine and naltrexone. 
This will create and then research the effectiveness of pharmacy 
management of MAT for people with opioid use disorder, a first in the 
country that has the potential to expand access to MAT the way that 
pharmacies have helped to expand access to naloxone across the state.

    Coordination Between federal, state and local agencies: The 
Governor's Overdose Prevention and Intervention Task Force is truly the 
hub of all activity in the fight against the opioid epidemic. The Task 
Force includes stakeholders and experts in fields ranging from public 
health and law enforcement to healthcare, community-based support 
services, insurance, academia, business, government and more. Family 
members of those who lost loved ones are also part of the Task Force, 
and have added an invaluable perspective that we in government and the 
private sector sometimes miss.

    The Task Force was created in August of 15, a Strategic Plan was 
presented to the Governor in December 2015, an Action Plan was created 
and released in May 2016, and a Public Awareness campaign was unveiled 
in June 2016.

    Today, Governor Raimondo continues to make turning the tide on the 
opioid crisis a top priority for her administration. Like so many Rhode 
Islanders, she has her own stories of personal connection and loss to 
the opioid epidemic, and she has encouraged agencies across our state 
government to be bold, creative, and determined in developing a 
response to opioid crisis. In July 2017, the Governor used her 
executive authority to direct state agencies, including the Department 
of Behavioral Healthcare, Developmental Disabilities, and Hospitals, to 
undertake a series of actions on opioid policy that fit into our core 
areas of emphasis: prevention, rescue, treatment, and recovery.

    On prevention, the Governor's executive order directed Rhode Island 
agencies to build from existing work that uses opioid prescriber data 
to target top prescribers of opioids in state and give those providers 
specific guidance on reducing unnecessary prescriptions, and we are 
developing creative, data-driven ways to ``nudge'' people who get 
opioid prescriptions to properly dispose of excess medication in order 
to reduce the risks that those prescriptions end up in the wrong hands. 
On rescue, the Executive Order also pushed agencies to place more 
naloxone in community settings so that anyone with the proper training 
can administer the naloxone and reverse the effects of an overdose. All 
hospitals in Rhode Island are on their way to having a ``level of 
care'' designation for opioid use disorder treatment, which guarantees 
a set standards for opioid use disorder care, regardless of where a 
patient is admitted in our state.

    For treatment and recovery, the Executive Order also asked agencies 
to hire medical professionals in high-risk communities who will help 
people get access to long-term treatment and recovery options, 
including long-term medication assisted treatment, and we continue to 
remove barriers that stand in the way of linking every Rhode Islander 
with substance use disorder to a peer recovery coach who can help be an 
ally and mentor to people in recovery. The Governor's executive order 
also directed agencies to do more to support Rhode Island's Centers of 
Excellence on substance use disorder care and treatment, which are 
integrated facilities that help people get access to acute mental 
health care and help people develop plans for long-term recovery.

    Other initiatives identified in the Executive Order include:

         Working with local law enforcement agencies to 
        implement pre-arrest diversion programs;

         Planning a multi-media education campaign to help 
        parents, youth, and families communicate about addiction and 
        the dangers of opioid use;

         Launching a Family Task Force comprised of the family 
        members of people who have died of an overdose, or who are 
        living with opioid-use disorder;

         Piloting and analyzing programs that encourage 
        disposal of excess opioids to reduce the risk of misuse or 
        diversion;

         Proposing a comprehensive harm reduction strategy 
        aimed at reducing negative consequences associated with 
        intravenous drug use.

    Use of Data to Inform Processes

    MODE Team: Rhode Island has implemented a Multidisciplinary Review 
of Drug Overdose Death Evaluation (MODE) Team which combines strategies 
of ``rapid response'' with ``community intervention.'' The Team is 
modeled after the multidisciplinary review processes for child deaths. 
The purpose of the MODE Team is to gain insight into emerging overdose 
trends, identify gaps in or opportunities for policy development and 
prevention programming and inform the distribution of mini----grants to 
Rhode Island communities for prevention efforts. Data sources come from 
RIDOH (Medical Examiner reports, Prescription Drug Monitoring Program 
(PDMP)), BHDDH (substance abuse and mental health treatment episodes), 
Medicaid (healthcare utilization), and RIDOC (incarceration history and 
medical records from incarceration). The MODE Team meets quarterly to 
review these data. Twenty-five MODE Team recommendations have been 
developed, with nine community-based drug overdose prevention mini-
grants distributed thus far.

    Surveillance, Response, and Interventions (SRI): This workgroup 
made up of staff from DOH and BHDDH review overdose information on a 
weekly basis. When overdoses exceed a certain threshold, alerts are 
issued to the community, law enforcement, and health providers.

    The Community OverDose Engagement (CODE) Program: CODE was 
developed in the Spring of 2017. The program calls for the RI 
Department of Behavioral Healthcare, Developmental Disabilities & 
Hospitals and the RI Department of Health to meet with communities 
identified via data tracking whose overdose activity repeatedly exceeds 
established thresholds.

    Because each community faces unique challenges in tackling the 
opioid epidemic, they must tailor their responses accordingly. To be 
successful, a collaborative approach is necessary in which all 
stakeholders have a significant say in the strategy, significant 
responsibility for implementing its components, and significant 
accountability for monitoring and demonstrating its effectiveness. 
Policies, programs, and initiatives should not be developed and 
implemented on the basis of intuition, anecdote, emotion, or political 
expediency. Instead, they should be informed by data and evidence. They 
should be designed to ensure that we bring an end to this epidemic via 
a compassionate approach based in good science and health-based 
solutions, rather than a combative approach based in fear, stigma, 
shame, and despair.

    The goal of CODE is for each community to implement a comprehensive 
approach that addresses the problem from all angles: prevention, 
overdose reduction, treatment and recovery support. Communities are 
encouraged to utilize data-informed and evidence-based practices when 
designing and implementing policies and programs.

    Results:

    This week, RI has released a press release announcing a 10 percent 
reduction in overdose rates in 2017. We are cautious to be overly 
optimistic in the face of a dynamic epidemic, but can't help but 
believe that we are perhaps seeing the results of the implementation of 
our strategic plan and complementary initiatives. The battle is far 
from over, and we know we need to press on in every aspect of our 
efforts, but a glimmer of hope is beginning to be revealed.

    Additional ideas for our Federal Partners to consider:

    There are numerous opportunities that would help the state's combat 
this epidemic and I humbly submit a few recommendations:

         An increase in funds is always a tremendous help. 
        While we appreciate the new grants which have been issued, 
        increasing the State's Substance Abuse Prevention and Treatment 
        Block Grant issued through SAMHSA would be the most expeditious 
        process for distributing funds for new initiatives. Block 
        grants provide opportunity for states to tailor interventions 
        to their particular needs. Discretionary grants require 
        significant administrative time and burden to under-resources 
        state agencies, and can delay their ability to quickly 
        distribute new funds. Increasing the Block Grant would allow 
        states to discuss project needs with their SAMHSA Project 
        Officer and receive feedback/approval for those needs. Outcomes 
        on all Block Grant dollars are reported to SAMHSA, therefore 
        there will be complete transparency on how the funds are used.

         Eliminate the prohibition for the use of federal funds 
        for treatment of incarcerated adults. RI's experience providing 
        MAT to individuals awaiting trial and for adjudicated 
        individuals prior to release demonstrates the effectiveness of 
        a thoughtful approach which can reduce overdose in a vulnerable 
        population, reduce relapse, encourage recovery and potentially 
        impact recidivism. State general revenue dollars cannot be 
        expected to sustain this effort alone. Engaging federal 
        partners, especially Medicaid, is essential for continuity of 
        care upon release.

         For RI, the continued availability of Medicaid 
        Expansion to support treatment is essential to our success.

         Any federal initiatives include the involvement of the 
        state agencies. Between the expertise and authority our staffs 
        have within the substance use disorder system, our agencies can 
        help to chart the right course.

         Treatment for substance use disorders leads to 
        recovery. Access to the treatment has been advanced by Medicaid 
        expansion. Continuing to support funding for Medicaid expansion 
        to single adults with low incomes is essential to helping more 
        people recover from substance use disorders.

         Many individuals living with substance use disorders 
        do not have access to transportation. Permitting mobile 
        methadone or buprenorphine provisions would eliminate that 
        barrier and make treatment more accessible. In addition, 
        expanding DATA waiver permissions to pharmacists and permitting 
        the dispensing of methadone from pharmacies would greatly 
        augment the country's treatment capacity in short order.

         Workforce development in the field of substance use 
        disorders is crucial with a standardized certification program 
        to license workers across all states. If this were coupled with 
        a loan forgiveness program, the workforce could grow to the 
        numbers needed.

         With elder opioid addiction on the rise, parity for 
        Medicare clients would be welcomed by all.

         Repealing the Institution for Mental Disease (IMD) 
        exclusion would allow for meaningful behavioral health care to 
        those who present with a substance use disorder, truly allowing 
        every door to be the right door.

    Conclusion: I appreciate the opportunity to present testimony 
before the Committee. Rhode Island has lost too many lives to drug 
overdoses, coming from every community in the state. Our work is 
focused on saving lives. I encourage the Committee and Congress to work 
with the NGA, NASADAD and ASTHO as well as other partners to leverage 
the collective knowledge and expertise of State Alcohol and Drug Agency 
Directors and Public Health Departments across the country to help end 
this epidemic.

                                 ______
                                 
                 [summary statement of rebecca l. boss]
    Addiction and overdose are claiming lives, destroying families, and 
undermining the quality of life across Rhode Island. For over a decade, 
opioid dependence and accidental drug overdose have been growing 
problems across the United States, and Rhode Island has been one of the 
hardest hit. Over the last 5 years our small state has lost more than 
1,200 people to drug overdoses, coming from every community in the 
state.

    Our work must be focused on saving lives. RI Governor Gina Raimondo 
recognized this and soon after her election in 2015, she knew the state 
needed a focused, statewide strategy to evaluate, prevent, and 
successfully intervene to reverse the overdose trends. She realized the 
scope of the problem had underlying issues, factors and consequence, we 
needed a new approach to combat this epidemic. Clearly, something 
different had to be created and implemented.

    Governor Raimondo established the Governor's Overdose Prevention 
and Intervention Task Force naming the Directors of BHDDH and the 
Department of Health (DOH) as Co-Chairs. The Task Force included 
stakeholders and experts in fields ranging from public health and law 
enforcement to healthcare, community-based support services, insurance, 
academia, business, government and family members of those who lost 
loved ones. The Task Force soon became the hub of all activity in the 
fight against the opioid epidemic.

    The Task Force created a Strategic Plan for Addiction and Overdose 
and recommended numerous strategies within four areas: prevention, 
rescue, treatment and recovery. The data-driven plan was created and 
soon after, with the help of Brown University a website was created 
(www.preventoverdoseri.org) where all efforts are tracked in a public 
and transparent fashion.

    The work of the Task Force along with the impact of federal 
programs, policies and funding, as well as the use of data to inform 
processes, Rhode Island is doing a tremendous amount of work and brings 
a unique perspective in the fight to end this epidemic.

                                 ______
                                 
    The Chairman. Thank you, Ms. Boss.
    Ms. Magermans, welcome.

                 STATEMENT OF ANDREA MAGERMANS

    Ms. Magermans. Thank you. Good morning, Chairman Alexander, 
Members of the Committee. Thank you for the opportunity to 
testify about the Wisconsin Prescription Drug Monitoring 
Program as part of Wisconsin's efforts to combat the opioid 
crisis.
    My testimony will focus on the creation and operation of 
the Wisconsin Enhanced Prescription Drug Monitoring Program, 
which was transformed to optimize its utility as a tool to 
address this epidemic.
    Today I would like to highlight how the Wisconsin ePDMP is 
unique as a clinical health care tool, a prescribing practice 
assessment tool, an interdisciplinary communication tool, and a 
public health tool.
    As a clinical health care tool, the Wisconsin ePDMP 
includes an enhanced user interface with a patient prescription 
history report that was designed to bring the most relevant 
information to the immediate attention of the user. This 
includes alerts informing providers of concerning prescription 
patterns or potential harmful interactions such as an opioid 
level over 90 morphine milligram equivalence, concurrent opioid 
and benzodiazepine prescriptions, or multiple prescribers or 
pharmacies.
    Alerts can also be added by prescribers to indicate 
patients who are on pain or addiction agreements. The alerts 
also notify providers of law enforcement-entered reports.
    Graphics on the patient report can help a prescriber 
quickly look for overdose risk factors or identify indications 
of a patient who obtains controlled substance prescriptions 
from multiple providers or who travels long distances to obtain 
controlled substance prescriptions. One-click access to a 
prescription history report is available through direct 
integration with electronic medical records.
    Through the direct EMR integration, a prescriber can click 
on a button within the patient's medical record to retrieve the 
patient's PDMP report within seconds. The prescription history 
report that is viewable is the same report that the provider 
would see when logging into the Wisconsin ePDMP. That way, a 
provider gets the benefits of the analytics and visualizations 
that are part of the redesigned patient prescription history 
report.
    As a prescribing practice assessment tool, the Wisconsin 
ePDMP allows prescribers to evaluate their own prescribing 
practices in relation to other prescribers in their specialty. 
The report shows prescribing volume by drug class and the 
average number of doses per prescription for the same drug 
classes both in relation to other prescribers of the same 
specialty. Those who oversee prescribers are also able to 
access prescriber metrics reports through a new and 
legislatively required medical coordinator role in the 
Wisconsin ePDMP.
    As an interdisciplinary communication tool, the Wisconsin 
ePDMP includes reports that law enforcement agencies are 
required by law to submit in Wisconsin about suspected opioid-
related overdose events, suspected violations of the Controlled 
Substances Act involving prescription drugs, and stolen 
controlled substance prescription incidents.
    The Wisconsin ePDMP then disseminates the reports to 
relevant users. This facilitates communication between law 
enforcement and health care professionals, and gives health 
care professionals a more complete picture of their patients' 
controlled substance prescription history to support more 
informed prescribing treatment and dispensing decisions.
    As a public health tool, statistics are made publicly 
available via the Public Statistics Dashboard, which provides 
interactive data visualizations about the controlled substance 
prescriptions dispensed in Wisconsin, law enforcement reports 
submitted to the ePDMP, and the use of the ePDMP by health care 
professionals and others.
    The efforts that were made to enhance the Wisconsin ePDMP 
have already had a large impact. Prior to January 2017, health 
care users made approximately 4,800 patient queries per day. 
Currently, health care professionals perform anywhere from 
25,000 to 35,000 queries per day. With the increased usage of 
the Wisconsin ePDMP due to a requirement for prescribers to 
review PDMP records before writing controlled substance 
prescriptions, the number of prescriptions and doses dispensed 
in Wisconsin has decreased.
    Even more striking is the coinciding decrease in the number 
of patients whose prescription history meets the criteria for 
data-driven alerts in the Wisconsin ePDMP system. The total 
number of concerning patient history alerts dropped by close to 
30 percent between January and September of this year, and 
specifically the number of multiple prescriber pharmacy alerts 
dropped by nearly 50 percent.
    The Wisconsin ePDMP is a successful tool because of the 
unique level of involvement of stakeholders and subject matter 
experts in the process to develop the enhanced PDMP 
application. Because the goal was to meet the users' needs for 
efficient, accurate, and actionable data, a concerted effort 
was made to include user and stakeholder engagement at every 
step of the development of the new system.
    The Department of Safety and Professional Services was 
recently awarded a Harold Rogers PDMP grant to continue 
enhancing the Wisconsin ePDMP, and the grant project will be a 
continuation of this collaborative model by working to 
implement user-led enhancements.
    The development of the Wisconsin ePDMP would not have been 
possible without interagency collaboration and grant funding 
from federal partners. DSPS is grateful for the federal grant 
awards it has received from SAMHSA, the Harold Rogers PDMP 
Grant Program, and the CDC, in partnership with the Wisconsin 
Department of Health Services.
    Thank you again for the opportunity to share this 
information with you about the Wisconsin ePDMP's role in 
addressing the opioid crisis in Wisconsin, and I will be happy 
to answer your questions.
    [The prepared statement of Ms. Magermans follows:]

                                ------                                

                 Prepared Statement of Andrea Magermans
    Chairman Alexander, Ranking Member Murray, and Members of the 
Committee, thank you for the opportunity to testify about the Wisconsin 
Prescription Drug Monitoring Program as part of Wisconsin's efforts to 
address the opioid crisis. I am Andrea Magermans, Managing Director of 
the Wisconsin Prescription Drug Monitoring Program (WI PDMP) in the 
Wisconsin Department of Safety and Professional Services. My testimony 
will focus on the creation and operation of the Wisconsin Enhanced 
Prescription Drug Monitoring Program (WI ePDMP) as a clinical 
healthcare, public health, and public safety tool. The WI PDMP was 
recently transformed to optimize its utility as a tool to address this 
epidemic.
Overview of WI PDMP
    I have been involved with the WI PDMP since it became operational 
in 2013 as a tool to help promote the safe prescribing and dispensing 
of opioids and other controlled substance prescription drugs. State 
PDMPs are widely recognized as effective tools for combatting the 
opioid epidemic by helping prevent prescription drug misuse, abuse, and 
diversion. In its most basic form, the WI PDMP is a statewide data base 
to which pharmacies and other dispensers submit information about the 
controlled substance prescriptions dispensed in the state. The WI PDMP 
operates in accordance with Wis. Stat. 961.385 and Wis. Admin. Code 
Chapter CSB 4. The Wisconsin Department of Safety and Professional 
Services (DSPS) oversees the operation of the WI PDMP in accordance 
with the policies established by the Wisconsin Controlled Substances 
Board.

    The WI PDMP collects approximately 750,000 dispensing records per 
month about controlled substance prescriptions in schedules II-V. It 
then makes the information available to authorized healthcare 
professionals, law enforcement agents, medical examiners, and State 
Regulatory Agency employees. De-identified PDMP data is also made 
available for public health research purposes. The WI PDMP has been 
successfully sharing data with other states, including its border 
stares, via the National Association of Boards of Pharmacy's 
Prescription Monitoring Interconnect (PMPi) since October of 13. This 
means that a WI practitioner who has reason to believe a patient picked 
up prescriptions in a different state can request records through the 
WI PDMP from the other state's PDMP, and vice versa.

    In 2015, although the WI PDMP had only been operational for several 
years, the decision was made to enhance and optimize the WI PDMP. 
Several factors went into the decision to transform the WI PDMP. State 
legislative requirements were going to demand functionalities for law 
enforcement and medical coordinator users that did not exist in the 
original WI PDMP software and that were not available in any other PDMP 
technology solutions. Further, legislation was going to be implemented 
requiring prescribers to review patient records in the PDMP prior to 
issuing a prescription order for any controlled substance medication. 
The previous PDMP system, although an effective tool, was cumbersome to 
use and had limited enrollment and utilization. Knowing that the new 
legislative requirement would increase the number of users and the 
number of daily patient queries dramatically, it was essential that the 
enhanced PDMP functionality help overcome the reported barriers to use 
of the PDMP system that was in place at the time. The goals of the 
development project were therefore to maximize the WI PDMP's clinical 
workflow integration, data quality capabilities, and public health and 
public safety uses. The result was the WI ePDMP, launched in January 
2017.
Key Features of the WI ePDMP
    Keeping these goals in mind, the development of the WI ePDMP 
redefined the role of the state's PDMP. The WI ePDMP has been 
transformed from a prescription tracking tool to a multi-faceted 
clinical and communication tool that considers the needs of all of its 
potential users. The WI ePDMP is now a robust, sophisticated clinical 
healthcare decision support tool, a prescribing practice assessment 
tool, an interdisciplinary communication tool, and a public health 
tool.
Clinical Healthcare Tool
    As a clinical healthcare tool, the goal of the WI ePDMP is to 
address controlled substance prescription drug abuse by helping 
healthcare professionals evaluate their patients' use of controlled 
substance prescription drugs to make more informed prescribing, 
treatment, and dispensing decisions. The information available in the 
WI ePDMP can also facilitate better coordination of care to patients 
seeing multiple professionals and help identify individuals who may be 
addicted to prescription drugs and may benefit from referrals to 
treatment.

    The WI ePDMP goes beyond the basics as a clinical healthcare 
decision support tool. The enhanced user interface has a redesigned 
patient prescription history report composed of a series of widgets 
that are designed to bring the most relevant clinical information in a 
patient's controlled substance prescription history to the immediate 
attention of the user. This first takes the form of alerts in red at 
the top of the report. A patient with no concerning history alerts or 
law enforcement-reported incidents would not have any alert buttons at 
the top of the report. The alerts inform prescribers of concerning 
prescription patterns or potential harmful interactions. Analytics of a 
patient's prescription history determine whether a patient has a daily 
opioid dose over 90 MME, concurrent opioid and benzodiazepine 
prescriptions, early refills, multiple prescribers or pharmacies, 
multiple same-day prescription or dispensing events, or long-term 
opioid therapy with multiple providers. Alerts can also be added by 
prescribers to indicate patients who are on pain or addiction 
agreements; the alerts can thereby facilitate communication among 
providers and better coordination of care. Further, the alerts are a 
mechanism for notifying providers of law enforcement reports of 
suspected opioid overdose events, controlled substance violations, and 
stolen prescriptions. This is a unique feature of the WI ePDMP that 
creates a completely different but clinically relevant data field for 
providers to consider when making prescribing and dispensing decisions. 
Clicking on any of the large red buttons at the top of the patient 
report provides more details about the criteria that triggered the 
alert and education about why that information is concerning. All the 
possible alerts at the top of a patient's prescription history report 
highlight the most relevant and concerning aspects of that patient's 
prescription history and give a more complete picture of that patient's 
controlled substance history to support more informed prescribing, 
treatment, and dispensing decisions.

    The use of analytics to provide actionable, meaningful information 
to healthcare users of the WI ePDMP system goes beyond the concerning 
patient history alerts at the top of the report. On the patient 
prescription history report, under any alerts and the patient 
demographics, a chart graphically shows a patient's opioid and 
benzodiazepine prescriptions over time by indicating the patient's 
cumulative morphine milligram equivalent (MME) dosage level as a line 
in relation to two benchmarks at 50 and 90 MME. According to the 
Centers for Disease Control and Prevention (CDC), risks for motor 
vehicle injury, opioid use disorder, and overdose increase at higher 
opioid dosages. Patients with 50-99 MME per day have 2x-5x the overdose 
risk as someone with 1-19 MME per day. Patients with more than 100 MME 
per day have up to 9x the overdose risk as someone with 1-19 MME per 
day.\1\ An explanation of the risk factor when a patient's level is 
above 50 or 90 is included right on the chart, and shading on the chart 
shows the additional risk factor of concurrent benzodiazepine and 
opioid prescriptions because, according to the CDC, concurrent use of 
an opioid and a benzodiazepine is likely to put a patient at greater 
risk for a potentially fatal overdose.\2\ This visualization provides 
education about safe prescribing practices and can help a prescriber 
quickly look for overdose risk factors prior to prescribing a 
controlled substance to a patient.
---------------------------------------------------------------------------
    \1\ http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1htm
    \2\ http://www.cdc.gov/mmwr/volumes/65/rr/rr6501e1htm
---------------------------------------------------------------------------
    Each patient report also includes a map widget that shows a visual 
depiction of the patient's controlled substance prescription history. 
This quick snapshot can help a provider identify indications of a 
patient who obtains controlled substance prescriptions from multiple 
prescribers or pharmacies or who travels long distances to obtain 
controlled substance prescriptions. Clicking on prescriber, dispenser, 
and patient icons on the map provides information about the name and 
the address of the individual or entity at that location. The map can 
therefore also facilitate communication among providers.

    Below the widgets in a patient prescription history report is a 
table of the patient's controlled substance prescriptions. The table 
includes information about the prescription drug, the quantity 
dispensed, the refill status, the date prescribed and date dispensed, 
the prescriber name and location, the dispenser name and location, the 
patient's name and address as they appear on the prescription record, 
and the method of payment the patient used when picking up the 
prescription. The table can be searched, and it can be exported for 
further manipulation.

    A lot of collaborative effort went into the design of the 
prescription history report to ensure the report met the needs of the 
prescribers and others who would be using the report as a clinical 
decision making tool. Before the WI ePDMP was launched in January 2017, 
prescribers, pharmacists, and other potential WI ePDMP end users 
reviewed designs and provided feedback about the redesigned report. The 
revamped report is only effective, however, if it is easy to access: 
efforts were therefore also made to make the site easier to use. The 
number of clicks required to access a patient report was reduced 
significantly compared to the previous PDMP system, the registration 
process was streamlined, and a responsive design was used so that the 
site and the patient reports render nicely on mobile devices. To 
further improve access to patient prescription histories, the WI ePDMP 
includes a patient panel which shows prescribers a list of patients to 
whom they have recently prescribed controlled substances. The list is 
searchable and sortable, and, once the desired patient name is found, 
it provides one-click access to the patient's prescription history 
report.

    The ultimate expression of one-click access to a patient's record 
in the WI ePDMP is through direct integration with electronic medical 
records (EMR). There are currently eight health systems live in WI with 
a direct EMR integration with the WI ePDMP, and several other systems 
have signed contracts to obtain the service and are testing the 
connection. Through the direct EMR-WI ePDMP integration, a prescriber 
can click on a button within the patient's medical record in the EMR 
platform to retrieve the patient's PDMP report within seconds. The 
provider does not have to log out of the EMR and log into the PDMP, nor 
does the provider have to enter the name and date of birth of the 
patient. What is more, the patient prescription history report that is 
returned to the provider is the same report that the provider would see 
when logging into the WI ePDMP website and looking up a patient, 
including the alerts and visualizations. That way, a prescriber gets 
the benefits of the analytics and visualizations that are part of the 
redesigned patient prescription history report, regardless of how the 
report was accessed. This type of integration was only possible because 
Wisconsin developed its own unique, homegrown PDMP platform.
Prescribing Practice Assessment Tool
    The only functionality that is currently available to users through 
the EMR integration is the review of a patient's prescription history 
report. In order to access other functionalities, a user must log into 
the WI ePDMP website. Users of the EMR integration are required to be 
registered with the WI ePDMP, so they are still able to log into the 
website to benefit from the additional functionalities. One of the 
functionalities available to prescribers is the review of their own 
prescribing practices through the Prescriber Metrics Report. In this 
self-assessment tool, prescribers can evaluate their own prescribing 
practices in relation to other prescribers in their specialty. The 
report includes a table showing all the controlled substance 
prescriptions that are attributed to a prescriber's DEA number in order 
to help prescribers look for unauthorized use of their DEA number. The 
report goes beyond just presenting a simple table, however. Indeed, 
located above the table on the report is a series of graphics showing 
prescribing volume by drug class and the average number of doses per 
prescription for the same drug classes. The values for a given 
prescriber are shown in relation to other prescribers in the same 
specialty area. The report also shows the number of patients the 
prescriber has who meet the criteria for the concerning patient history 
alerts or about whom law enforcement agencies have submitted violation, 
overdose incident, or stolen prescription reports. Prescribers also 
have insight into the total number of controlled substance 
prescriptions they have written compared to the number of patient 
queries they or their delegates have performed. This gives prescribers 
a basic estimated indication of whether they are adhering to the 
requirement to review PDMP records before writing controlled substance 
prescriptions. For more details about their and their delegates' use of 
the PDMP system, prescribers can also access WI ePDMP usage audit 
trails when logged into the WI ePDMP website. The knowledge gained by 
prescribers through these self-assessment functionalities empowers 
prescribers to maintain safe prescribing practices.

    Furthermore, Medical Coordinator users of the WI ePDMP can 
encourage prescriber accountability by assessing the prescribing 
practices of the prescribers they oversee. The WI ePDMP medical 
coordinator role was created pursuant to 2015 Wisconsin Act 266, which 
requires the WI ePDMP to disclose information to a person who medically 
coordinates, directs, supervises, or establishes standard operating 
procedures for a practitioner if the person is evaluating the job 
performance of the practitioner or is performing quality assessment and 
improvement activities, including outcomes evaluation or the 
development of clinical guidelines. A new role was developed for these 
purposes, and an individual can register to become a Medical 
Coordinator user. Medical Coordinators have limited functionality that 
allows them to manage lists of the prescribers they oversee and view 
the Prescriber Metrics Report for the individual prescribers. Medical 
Coordinators do not have access to personally identifiable data, so 
they do not see the complete prescribing history of the prescribers. 
Rather, they see the metrics about prescribing volume by drug class. 
The Medical Coordinator functionality is currently being enhanced to 
respond to feedback from the Medical Coordinator users of the system. A 
future release of the Medical Coordinator role will allow an easier 
comparison among providers that a Medical Coordinator oversees.
Interdisciplinary Communication Tool
    Since March 2016, law enforcement agencies have been required to 
submit information to the WI PDMP about specific events, and the WI 
PDMP has been required to disseminate the information to relevant PDMP 
users. The previous PDMP system in Wisconsin did not allow this 
functionality, so part of the redesign was to incorporate this 
functionality in a meaningful way. The WI ePDMP includes a secure login 
for law enforcement employees and allows them to submit reports about 
suspected opioid-related overdose events, suspected violations of the 
controlled substances act involving prescription drugs, and stolen 
controlled substance prescription incidents. The reports are reviewed 
by PDMP administrative staff to ensure they are attributed to the 
correct patient in the WI PDMP data base and are relevant to the type 
of report submitted. The alerts themselves contain a disclaimer stating 
that ``Law enforcement agencies are required by Wis. Stat. 961.37 to 
submit reports based on `reasonable suspicion' or `belief.' The alert 
does not necessarily mean that the individual was arrested, convicted 
or is guilty of any violation of criminal law.'' Once the submissions 
are processed, they are disseminated to relevant WI ePDMP users in two 
ways. Prescribers who have prescribed to the patients in the incidents 
receive emails indicating that they have a patient about whom a law 
enforcement report has been submitted. They then need to log in and 
check their alert tab to view the details of the alert, including the 
contact information of the submitting law enforcement agency to request 
more information about the incident, if desired. The report is also 
displayed as an alert at the top of a patient prescription history 
report for healthcare professionals who are accessing the PDMP record 
of the patient in question prior to prescribing to, dispensing to, or 
treating the patient. The providers therefore have a more complete 
picture of the patient's involvement with controlled substances and can 
make better-informed prescribing, dispensing, and treatment decisions. 
The WI ePDMP thus functions as a communication tool between law 
enforcement and healthcare professionals. The reports submitted by law 
enforcement are also tracked for public health reporting purposes.
Public Health Tool
    Another unique feature of the WI ePDMP is the Public Statistics 
Dashboard, which provides interactive data visualizations about the 
controlled substance prescriptions dispensed in Wisconsin, the law 
enforcement reports submitted to the WI ePDMP, and the use of the WI 
ePDMP by healthcare professionals and others. The Public Statistics 
Dashboard was developed as part of a Harold Rogers grant project with 
the intent of providing statewide and county-level data to the public. 
Previously, DSPS created quarterly statistics sheets with basic 
dispensing information and a heatmap showing the density of controlled 
substance prescriptions dispensed in Wisconsin. The Public Statistics 
Dashboard makes similar information available in an interactive format 
and includes additional statistics, many of which are available for 
specific counties. The WI ePDMP also provides a unique registration and 
login functionality for researchers, who can upload information about 
the studies they are undertaking and retrieve de-identified data sets. 
The WI ePDMP thereby supports public health research on trends in 
dispensing of opioids and other prescription controlled substances.
Impact and Effectiveness of the WI ePDMP
    Many of the statistics available on the Public Statistics Dashboard 
show that the efforts that were made to enhance the WI ePDMP have 
already had a large impact. Before the launch of the WI ePDMP in 
January 2017, there were approximately 19,000 registered healthcare 
users in the previous PDMP system. All users had to re-register in the 
WI ePDMP, which is why efforts were made to streamline the registration 
process. The process proved easy for many users, some of whom even 
reported that they completed registration within a matter of seconds 
during a patient encounter. By March 30, 2017, there were over 31,000 
registered healthcare users, and there are currently nearly 42,000 
registered healthcare users of the WI ePDMP. The increased usage of the 
WI ePDMP is also reflected in the number of daily patient queries made 
by healthcare professionals. Prior to January 2017, healthcare users 
made approximately 4,800 patient queries per day, on average. In 
anticipation of the requirement for prescribers to review patient 
records in the WI ePDMP that went into effect on April 1, 2017, there 
were 17,489 patient queries made by healthcare professionals in 1 day. 
By late August 2017, there were as many as 35,000 patient queries made 
in a day. Currently, healthcare professionals perform an average of 
over 20,000 patient queries per day, with weekday numbers ranging from 
25,000 to 35,000 daily patient queries, and weekend numbers remaining 
under 5,000 patient queries per day.

    Beyond the increased registration and utilization of the WI ePDMP 
system, it is possible to see the effects of the WI ePDMP on 
prescribing practices. It is important to note that the WI ePDMP is 
just one part of the State of Wisconsin's efforts to promote safe 
prescribing of controlled substances, so the changes noted cannot 
solely be attributed to the WI ePDMP. Nonetheless, the number of opioid 
prescriptions and doses dispensed in WI has decreased significantly 
from January 2016 through June 2017. Data from the WI ePDMP show that 
175,269 fewer opioid prescriptions were dispensed from April 1, 2017 to 
June 30, 2017, compared to the first quarter of 2016, a 14.1 percent 
decrease. This equates to13 million fewer doses dispensed, a 16.4 
percent decrease. Furthermore, there has been a dramatic decrease in 
the number of patients whose prescription history meets the criteria 
for the data-driven concerning patient history alerts in the WI ePDMP 
system. The total number of concerning patient history alerts dropped 
by close to 30 percent from January 2017 to September 2017. The 
decrease is particularly noticeable for the number of patients with 
multiple providers or pharmacies. The analytics for this type of alert 
were applied to data from previous years, and a significant change can 
be seen in February 2017, right after the launch of the WI ePDMP. Prior 
to January 2017, there were consistently over 21,000 alerts per month. 
This number dropped below 21,000 in February 2017. Another steady 
decrease began in April of 17, when the requirement for prescribers to 
review patient records in the WI ePDMP went into effect. The number of 
alerts in April 2017 was less than 19,000, and by September 2017, the 
number had dropped below 11,000. From January 2017 to September 2017, 
the number of multiple prescriber or pharmacy alerts dropped by nearly 
50 percent, from 21,088 in January to 10,264 in September. Part of this 
change is likely due to the greater number of prescribers accessing the 
WI ePDMP because of their requirement to review. Beyond the number of 
prescribers who are accessing the WI ePDMP, however, this decrease can 
also be considered an indication of the effectiveness of the WI ePDMP 
because it is based on a specific report element that is presented back 
to end users. End users are alerted to high patient MME, multiple 
provider episodes, and opioid and benzodiazepine prescriptions 
overlaps, as well as overdose events a patient may have been involved 
in. It appears that the analytics going into the alerts and the way the 
relevant information is being presented to the end users is changing 
prescribing behaviors.
Development Process
    Beyond the unique key features of the WI ePDMP, the WI ePDMP is 
also unique because of the level of involvement of stakeholders and 
subject matter experts in the process to develop the enhanced PDMP 
application. The project goal was not only to address shortcomings of 
previous system, but also to reimagine the role of the system in 
addressing opioid crisis. The strong support for the project came from 
agreement among stakeholders, legislators, and administration that the 
epidemic required a strong response. Because the goal was to meet the 
users' needs for efficient, accurate, and actionable data, a concerted 
effort was made to include user and stakeholder engagement at every 
step of the process. This meant that there was subject matter expert 
and user review and involvement during the scoping, designing, 
development, and testing of the new application. DSPS collaborated with 
professional associations to identify subject matter experts and 
potential users who were regularly involved in continual feedback 
loops. The development process was iterative, with 2-week development 
cycles. Users would review designs and provide feedback; the feedback 
would then be implemented in the development of the application. The 
iterative improvement process continued throughout 2016 before 
launching the new PDMP system and still continues to this day as 
informed by feedback from actual users in the field. One example of the 
impact of continued feedback loops on the functionality of the WI ePDMP 
system decreased the number of clicks to get to get to a patient's 
record by suggesting that the cursor on a search page be defaulted to 
the first name field. The suggestion was made by multiple users, and 
the change was subsequently implemented. This small change not only 
improved the user experience with the WI ePDMP but also showed the end 
users that they are an important part of the development and success of 
the system. The increased user buy-in has given users a sense of pride 
and ownership, which has led in part to the success of the WI ePDMP. 
Prescribers in particular are beginning to see checking the PDMP as 
something more than just a requirement; they are recognizing it as a 
useful clinical tool and making suggestions to continue to make it 
better. DSPS was recently awarded a Harold Rogers PDMP grant to 
continue enhancing the WI ePDMP, and the grant project will be a 
continuation of this collaborative model by working to implement user-
led enhancements.

    The development of the WI ePDMP would not have been possible 
without interagency collaboration and grant funding from federal 
partners. DSPS is appreciative of the opportunities that have been 
afforded to it through federal grant awards from the Substance Abuse 
and Mental Health Services Administration (SAMHSA), the Office of 
Justice Programs in the Bureau of Justice Assistance at the U.S. 
Department of Justice, and the CDC. The SAMHSA grant allowed DSPS to 
implement a previous PDMP-EMR integration and work toward the current 
direct EMR-PDMP integration model. DSPS received two Harold Rogers PDMP 
Enhancement Grants in 2014 and 2015, first to build the Public 
Statistics Dashboard, which was originally envisioned as a stand-alone 
website along side the previous PDMP system, and later to build the WI 
ePDMP. Grant funding from a CDC Drug Overdose Prevention Grant in 
partnership with the Wisconsin Department of Health Services further 
supported the development of the WI ePDMP.
Lessons Learned/Recommendations
    The involvement of PDMP administrators, subject matter experts, and 
potential WI ePDMP users at every step of the development process was 
critical to the success of the WI ePDMP. The administrators of other 
State PDMPs have shown a keen interest in learning about and from the 
experience of developing the WI ePDMP, not only from a technology 
perspective but also from a project methodology perspective. 
Collaboration among PDMP administrators should be encouraged by 
providing opportunities for PDMP administrators to meet, discuss 
challenges, and learn from each other's experiences. It is difficult to 
know the types of functionalities to strive for without first 
understanding the realm of possibilities by knowing about what is going 
on in other states. The sharing of actual PDMP technology could also be 
facilitated through the encouragement of open-source PDMP software 
solutions. The WI ePDMP has also been successful because of the way it 
redefined the role of the State PDMP and took bold steps to transform 
the PDMP system to meet the needs of those who use it. This type of 
innovation should be encouraged but is sometimes stifled because of a 
lack of awareness of possibilities. In general, states are very 
appreciative of grant funding opportunities to improve their PDMP; 
however, they may be tempted to defer to the use of grant dollars for 
known solutions or vendors if they do not have the drive, awareness, 
and support to innovate. In the case of the WI ePDMP, innovation led to 
a successful home-grown solution that is tailored to the situation in 
WI. Furthermore, the involvement of PDMP administrators at every step 
of the development process proved invaluable in WI, but this 
involvement is not always the case, especially when funding involving a 
state's PDMP is awarded to an agency that does not house the state's 
PDMP. Wisconsin has been fortunate to be able to collaborate closely 
with the Wisconsin Department of Health Services to enhance the WI 
ePDMP as part of a CDC grant. Funding opportunities that involve a 
state's PDMP should require that PDMP admins be directly involved in 
the projects.
Conclusion
    Thank you again, Chairman Alexander, Ranking Member Murray, and 
Members of the Committee, for the opportunity to share this information 
with you about the WI ePDMP's role in addressing the opioid crisis in 
WI. The transformation of the WI ePDMP into a robust clinical decision 
support tool has been well received by the medical community in WI. The 
success of the WI ePDMP as a tool to help combat the opioid abuse 
epidemic would not have been possible without the involvement of 
stakeholders and users throughout the development process. The 
collaborative nature of the WI ePDMP development project, including the 
involvement of PDMP administrative staff, interagency support, and 
federal grant funding, has led to impressive results and has set the 
stage for continued enhancements to the WI ePDMP based on user feedback 
to ensure that it remains an effective tool in the State of Wisconsin's 
efforts to combat the opioid crisis.

                                 ______
                                 
                [summary statement of andrea magermans]
    Chairman Alexander, Ranking Member Murray, and Members of the 
Committee, thank you for the opportunity to testify about one part of 
Wisconsin's efforts to address the opioid crisis. My testimony will 
focus on the creation of the Wisconsin Enhanced Prescription Drug 
Monitoring Program (WI ePDMP) to optimize its utility as a clinical 
healthcare, public health, and public safety tool. The development of 
the WI ePDMP redefined the role of the PDMP: it is now a robust 
clinical healthcare decision support tool, a prescribing practice 
assessment tool, an interdisciplinary communication tool, and a public 
health tool.

    As a clinical healthcare tool, the WI ePDMP includes an enhanced 
user interface and a redesigned patient prescription history report 
that is designed to bring the most relevant clinical information in a 
patient's controlled substance prescription history to the immediate 
attention of healthcare users of the WI ePDMP.

    As a prescribing practice assessment tool, the WI ePDMP allows 
prescribers to evaluate their own prescribing practices in relation to 
other prescribers in their specialty through the Prescriber Metrics 
Report. The knowledge gained by prescribers through these self-
assessment functionalities empowers them to maintain safe prescribing 
practices. Those who oversee prescribers are also able to access 
Prescriber Metrics Reports through a new Medical Coordinator role in 
the WI ePDMP.

    As an interdisciplinary communication tool, the WI ePDMP includes 
reports submitted by law enforcement about suspected opioid-related 
overdose events, suspected violations of the controlled substances act 
involving prescription drugs, and stolen controlled substance 
prescription incidents and disseminates the reports to relevant WI 
ePDMP users. It facilitates communication between law enforcement and 
healthcare professionals and gives healthcare professionals a more 
complete picture of their patients' controlled substance history to 
support more informed prescribing, treatment, and dispensing decisions.

    As a public health tool, statistics are made publicly available via 
the Public Statistics Dashboard, which provides interactive data 
visualizations about the controlled substance prescriptions dispensed 
in Wisconsin, the law enforcement reports submitted to the WI ePDMP, 
and the use of the WI ePDMP by healthcare professionals and others.

    Beyond these key features, the WI ePDMP is unique because of the 
level of involvement of stakeholders and subject matter experts in the 
process to develop the enhanced PDMP application. Because the goal was 
to meet the users' needs for efficient, accurate, and actionable data, 
a concerted effort was made to include user and stakeholder engagement 
at every step of the process.

                                 ______
                                 
    The Chairman. Thank you, Ms. Magermans.
    Secretary Tilley, welcome.

                STATEMENT OF HON. JOHN C. TILLEY

    Secretary Tilley. Thank you, Chairman, for your welcome 
again. Thank you for that. I want to say what an honor it is to 
be here, and also to say to you this is heavy stuff. But if I 
may just take a moment, Chairman, and say that growing up in 
West Kentucky, very near where Senator Paul--and thank you for 
that nice introduction, Senator. I've seen your passion 
firsthand for reform, and your intellect on these issues is 
unquestioned. But he knows how closely we live to Tennessee, 
and also how closely we are aligned with the national media.
    Many of my family members back in the day from Kentucky 
went to the polls trying to vote for the Chairman, Lamar 
Alexander, because of that. Also we were readers of your little 
plaid book, everything you need to know. It's kind of like 
Kinder contained in this book. It's certainly a Bible for us, 
and thank you for that. If you think that's pain, it certainly 
is.
    The Chairman. You may be the best witness we've had in 
years.
    [Laughter.]
    Secretary Tilley. Thank you. Goodnight. I've had a great 
run.
    [Laughter.]
    Secretary Tilley. Again, it is such heavy stuff. During the 
course of debates we had over 3 years to come to what became 
known as the heroin bill in Kentucky, Senator, as you remember, 
we kept the North Star with us in Kentucky, a young man by the 
name of Wes Jenkins, who at 12 years old was part of a Little 
League World Series championship team from Louisville. Not 
often do American teams win the Little League World Series, and 
certainly not from Kentucky, a smaller state like ours.
    But, Senator, you remember that day. I remember the last 
pitch and seeing them pile on one another, beating Japan that 
day. They were not favored to win.
    Ten years later, Wes Jenkins died of an overdose, the same 
story. He went for oral surgery when he was playing college 
baseball, and three stints in rehab later he overdosed the day 
he stepped out of that third rehab.
    We never forgot Wes Jenkins, him being also the nephew of 
one of my colleagues in the House and Senate.
    We worked together, put down any partisanship, no room for 
that, locked arms and got some good things done. I think 
without the help of the Federal Government, we could not have 
done what we've done in Kentucky.
    Let me start with our Department of Corrections response. 
Make no mistake, this opioid pandemic--it's no longer an 
epidemic--has had an amazing, incredible negative impact on our 
criminal justice system. It's a public health nightmare being 
handled in courtrooms and jails and prisons, and that is part 
of the problem. We don't have time to address all that today.
    One of the things we're most proud of is the fact that 
we've increased treatment by 1,100 percent thanks to some of 
the resources you've given us. The ROI on treatment behind our 
walls is about almost five dollars. It cuts recidivism, cuts 
rates of mental illness. We track these offenders once they 
leave our prisons and jails. In terms of getting to that ROI, 
that return on investment, it's money well spent.
    We also have something that's been really chronicled 
nationally, a pilot program using naltrexone or vivitrol. We 
give a shot 30 days before release, we give a shot the day of 
release, and give a shot 30 days after, with the injection 
being every 28 days or 30 days to battle this incredible 
chronic brain disease, and we have seen great early results 
from that program. The return on investment, even with the 
expense of that drug, is very high. The return is very high. 
Again, we received a lot of attention for that and would like 
to expand that. We're doing that as we speak.
    We're also proud of our coordination with law enforcement 
and public health. The Cabinet for Health and Family Services, 
that is unprecedented now in our state. The CDC in their 
recommendations and their money has allowed us to track 
overdoses in ways with law enforcement we never have.
    We've also been able to collaborate for training protocols 
for physicians and nurses and dentists on many prescribing 
practices that we know are very critical to this problem.
    We've also been able to up the distribution of naloxone in 
ways that have never been seen, and I would submit to you that 
we need over-the-counter naloxone. The only use we have for 
that is to battle back and reverse these overdoses, and so we 
do that.
    My good friend Rebecca, we've worked together for years 
now, and we are using now the Rhode Island model in Kentucky. 
I'm really proud to report--and what I mean by that is the one 
she spoke of using peer specialists in the emergency 
departments, and also using bridge clinics at the same time. 
It's an ambitious goal to reach, but we've done that. In the 
first week we used it at the University of Louisville just 
recently, Senator, we had the first five people to walk in and 
overdose. By the way, we had 13,000 overdoses in Kentucky 
emergency rooms alone in 2016. But the first five who walked 
in, four entered treatment. That's a great sign, and that 
actually follows the national trend line from Rhode Island. 
Eighty percent will do that.
    Before that model, we lost 13,000 opportunities to link 
somebody to treatment who came in with an overdose. We lost 
1,404 Kentuckians. As you know, the numbers are staggering. In 
the last 10 years, or at least between 2006 and 2016, we lost 
471,000 Americans. That can be lost.
    Again, I see my time is up. There is too much to cover. I 
hope that the questions come fast to us because we would love 
to cover some of the unique things and innovative ways we're 
attacking it in Kentucky.
    Thank you, Chairman.
    [The prepared statement of Secretary Tilley follows:]

                                ------                                

                   Prepared Statement of John Tilley
Kentucky's Crisis
    2016 proved to be a deadly year for the citizens of the 
Commonwealth of Kentucky, who saw 1,404 of their family members, 
friends, and neighbors die from drug overdoses. Since 2012, drug 
overdoses have accounted for more accidental Kentucky deaths than motor 
vehicle crashes. The leading culprit, fentanyl, a potent synthetic 
opioid, was detected in 47 percent of overdose deaths, up from 34 
percent in 2015. According to the Kentucky State Police, there was a 
6,000 percent increase in laboratory samples submitted to the Central 
Forensic Laboratory testing positive for fentanyl from 2010 to 2016. 
Last year, in addition to fentanyl, the Kentucky State Police reported 
samples from 10 different counties testing positive for carfentanil, a 
fentanyl derivative that is 100 times more potent than fentanyl itself. 
Fentanyl continues to engulf Kentucky as the Kentucky State Police 
report that the number of submissions testing positive for fentanyl in 
the first two quarters of 2017 has already exceeded the 2016 total. The 
2017 samples also included several potent fentanyl derivatives such as 
cyclopentylfentanyl, acetylfentanyl, butyrylfentanyl, acrylfentanyl, 
furanylfentanyl, and carfentanil. According to Appalachia HIDTA's 2018 
Threat Assessment, Kentucky remains particularly vulnerable to drug 
trafficking organizations because of its central geographical location 
and many interstate highways.

    In addition to increased rates of substance use disorders and 
overdose deaths, the opioid epidemic has also brought the threat of 
blood borne pathogens such as viral hepatitis and human 
immunodeficiency virus (HIV). According to the Centers for Disease 
Control and Prevention, 54 of the top 220 counties most vulnerable to a 
rapid outbreak of HIV are located in Kentucky. In response to the 
devastating HIV outbreak in nearby Austin, Indiana in 2014, Kentucky 
became the first southern state to authorize the creation of syringe 
exchange programs, which are designed to reduce the incidence of needle 
sharing and prevent the spread viral hepatitis and HIV. There are 
currently 41 Harm Reduction Syringe Exchange Programs (HRSEPs) 
operating across the Commonwealth since the General Assembly granted 
county officials the power to approve such programs. Aside from HIV, 
forms of viral hepatitis--such as hepatitis C--also pose a large threat 
to the residents of Kentucky. From 2008 to 2015, Kentucky had the 
highest rate of acute hepatitis C infections in the United States.
Department of Corrections Response
    The Kentucky Department of Corrections remains the single largest 
treatment provider in the Commonwealth. In 2004, the department had 475 
substance abuse treatment slots available. Today, it has 5,901 
treatment slots, representing a 1,100 percent increase since 2004. The 
substance abuse treatment programs utilize evidence-based cognitive 
behavioral therapy and therapeutic community models. According to a 
recent study by University of Kentucky professors, the department's 
treatment programs resulted in a strong return on investment--$4.29 of 
cost avoidance for every $1 spent in fiscal year 2015. During the 12 
months following release, 70 percent of participants were not re-
incarcerated, 85 percent maintained housing, and 68 percent were 
employed at least part-time. The study participants also reported 
decreased illicit drug use, decreased feelings of serious depression 
and anxiety, and decreased instances of suicidal ideation.

    In 2015, the Department of Corrections began a pilot project aimed 
at reducing fatal overdoses among inmates released on parole. The 
department uses a validated risk and needs assessment to target those 
inmates most vulnerable to overdoses and offer them the chance to 
voluntarily receive injections of naltrexone, a long-acting opioid 
receptor antagonist, before they leave prison. Within 24 hours of being 
paroled, participating inmates meet with social service clinicians at 
their local Probation and Parole offices for assistance determining 
health care coverage eligibility and setting up an appointment for the 
inmate's next naltrexone injection. The initial results from the pilot 
project have been so promising that representatives from five other 
states, tribal authorities from Montana, and the U.S. Virgin Islands 
have observed the program.
Coordination between Public Health and Law Enforcement in Kentucky
    The opioid epidemic has demanded intense collaboration between the 
Kentucky Department of Public Health and the Kentucky Office of Drug 
Control Policy. Recently, the Department of Public Health contracted 
with the Kentucky Injury Prevention and Research Center (KIPRC) to 
provide data analysis and technical support in joint endeavors with the 
Office of Drug Control Policy. Over the last few years, KIPRC and the 
Office Drug Control Policy have utilized grant funding from the Centers 
from Disease Control and Prevention to create the Commonwealth's drug 
overdose surveillance program. The drug overdose surveillance program 
compiles data on drug overdose deaths from county coroners, physicians, 
and the Office of the State Medical Examiner into one data set, which 
is used to compile a detailed annual overdose death report. In addition 
to the drug overdose surveillance program, the partnership between 
KIPRC and the Kentucky Office of Drug Control Policy has also led to 
the development of training protocols for physicians, nurses, and 
dentists on appropriate opioid prescribing methods. Thousands of 
Kentucky law enforcement officers have been trained on the proper 
treatment of opioid overdoses and the use of emergency naloxone kits 
thanks to the partnership as well.
21st Century Cures Act Programming
    The Office of Drug Control Policy worked closely with 
representatives from the Cabinet for Health and Family Services to 
develop a comprehensive strategy for using funds from the 21st Century 
Cures Act. The Kentucky Opioid Response Effort (KORE) is a 
multidisciplinary team established to administer the funds granted to 
the Commonwealth from the Cures Act to bolster evidence-based treatment 
interventions aimed at reducing the impact and prevalence of opioid use 
disorder among non-fatal drug overdose survivors, pregnant and 
parenting women, and incarcerated individuals.

    Initiatives aimed at survivors of non-fatal overdoses include the 
creation of specialized medication-assisted treatment bridge clinic 
programs and the placement of peer recovery specialists in emergency 
departments. The specialized bridge clinics initiate a medication-
assisted treatment protocol with overdose victims while they are still 
in hospital in order to stabilize them long enough to obtain treatment 
in the community. KORE funded one of the first bridge clinics at the 
University of Louisville's emergency department in partnership with 
Centerstone, a community mental health center earlier this month. On 
the first day of operation, peer recovery coaches deployed to the 
hospital's emergency department contacted five individuals treated for 
opioid overdoses. Four of the five opioid overdose survivors contacted 
by peer recovery coaches opted for immediate entry into treatment.

    The peer recovery specialist initiative, which was modeled after 
Rhode Island's Anchor ED program, incentivizes Kentucky hospitals to 
contract with certified peer recovery specialists who could counsel 
recent drug overdose survivors while they are still in the emergency 
department and help them enroll in a treatment program if the survivor 
chooses treatment in that instance. Some additional funds are being 
used to distribute naloxone at community awareness events, emergency 
departments, and syringe exchange programs

    The initiative aimed at pregnant and parenting women will create an 
integrated continuum of care model, aimed at synchronizing obstetrics 
care, primary care, medication-assisted treatment provider care, and 
case management. Once the model is perfected, a training program will 
be developed and offered to healthcare and treatment providers.

    Finally, part of the 21st Century Cures Act funding will be used to 
create a targeted employment pilot program for state and county inmates 
reentering society with a history of opioid use disorder. The program 
will hire employment specialists to assist former inmates in finding 
and maintaining employment in Northern and Eastern Kentucky, which are 
two regions that have been most affected by the opioid epidemic.
                                 ______
                                 
                   [Summary Statement of John Tilley]
Kentucky's Crisis
         In 2016, Kentucky lost 1,404 citizens to drug 
        overdoses.

         Since 2012, drug overdose deaths have accounted for 
        more accidental Kentucky deaths than motor vehicle crashes.

         Medical examiners detected fentanyl in 47 percent of 
        Kentucky overdose victims in 2016, up from 34 percent in 2015.

         The Kentucky State Police Central Forensic Laboratory 
        has also seen an increase in the detection of potent fentanyl 
        derivatives such as carfentanil and cyclopentylfentanyl.

         Kentucky is at an elevated risk of an outbreak of 
        blood borne pathogens such as HIV and hepatitis C due to unsafe 
        injection practices among those suffering from opioid use 
        disorder.

         According to the Centers for Disease Control and 
        Prevention, Kentucky has 54 of the 220 counties most vulnerable 
        to a rapid outbreak of HIV.
Department of Corrections Response
         The Kentucky Department of Corrections has increased 
        substance abuse treatment slots from 475 in 2004 to 5,901 in 
        2017, a 1,100 percent increase in treatment capacity.

         According to a recent study, the department's 
        substance abuse treatment program resulted in a $4.29 cost 
        avoidance for every dollar spent on the program.

         In 2015, the department created a pilot program 
        designed to reduce fatal overdoses among inmates released on 
        parole by providing them the opportunity to receive naltrexone 
        injections prior to release. Preliminary results from the pilot 
        have been so promising, that representatives from five other 
        states, tribal authorities from Montana, and delegates from the 
        U.S. Virgin Islands have observed the program.
Coordination between Public Health and Law Enforcement in Kentucky
         The Kentucky Department of Public Health and the 
        Kentucky Office of Drug Control Policy have collaborated to 
        create Kentucky's drug overdose surveillance system using grant 
        funding from the Center for Disease Control and Prevention.

         The collaboration has also resulted in the development 
        of training protocols for physicians, nurses, and dentists on 
        appropriate opioid prescribing practices.

         Thousands of Kentucky law enforcement officers have 
        been trained to treat opioid overdoses with emergency naloxone 
        kits thanks to the collaboration as well.
21st Century Cures Act Programming
         Pilot sites for the creation of treatment bridge 
        clinics and the placement of certified peer recovery 
        specialists in emergency departments have begun to operate.

         The initiative aimed at pregnant and parenting women 
        will create an integrated continuum of care model, aimed at 
        synchronizing obstetrics care, primary care, medication-
        assisted treatment provider care, and case management.

         A targeted employment pilot program aimed at state 
        county inmates who have a history of opioid use disorder is 
        being develop for sites in Northern and Eastern Kentucky.

         Additional funds are being used to hold community 
        training sessions and distribute emergency naloxone kits.

                                 ______
                                 
    The Chairman. Thank you very much, Secretary Tilley, and 
thanks for bringing the little plaid book with you.
    Secretary Tilley. I hope it worked. Thank you.
    The Chairman. I'll say to the Senators who have come in, 
we've had very interesting testimony from four witnesses who 
are on the front lines of states dealing with opioids, and now 
we'll go to a 5-minute round of questions. We thank you for the 
testimony.
    We'll begin with Senator Young.
    Senator Young. Well, thank you, Chairman. That's a good way 
for me to step off your lead in there, because Indiana has 
indeed been on the front lines of this opioid crisis, and I 
thank all of our witnesses for their testimony and expertise in 
this area.
    I visited with a number of local sheriffs throughout 
Indiana. I used to represent, in the House of Representatives, 
Indiana's 9th Congressional District, which included Scott 
County, Indiana. That is where Austin, Indiana is located that 
gave national attention to that county, not in the best way, 
but they fought their way back and continue to.
    Many local sheriffs throughout the state have a strong 
suspicion that their inmates not only have opioid addiction 
challenges but also have HIV, Hep C, or TB. But they're left 
with this moral dilemma. You see, they have a limited budget to 
take care of their criminal justice matters each year, but they 
also are supposed to attend to the health care of those 
individuals. If they test these inmates and identify that they 
have Hep C, that they have TB and so forth, then that could 
conceivably and very realistically deplete the entire law 
enforcement budget they have for a year. These public servants 
are on the horns of a human rights dilemma.
    Director Boss, you've made some suggestions in your 
testimony about how we can better treat, as a Nation, 
incarcerated individuals. You also touched on how we can better 
treat individuals awaiting trial. Would you kindly elaborate on 
this issue generally and some of the suggestions you have for 
us?
    Ms. Boss. I would, and thank you for that opportunity. 
Individuals awaiting trial who are not yet adjudicated are 
often some of the most complex individuals that we see because 
they're coming from the street to a center that will house them 
with the multiple medical issues that you identify, including 
addiction and in the stages usually of withdrawal when they are 
opioid addicted.
    One of the things we find most helpful is really addressing 
that health care need. An addiction is a disease, and addiction 
treatment is a health care issue. Providing medication, as you 
would for any other health care issue, in alleviating those 
withdrawal symptoms and providing stability for the individual 
in their addiction has been very successful.
    What we see is individuals sometimes coming in already on 
medication-assisted treatment. Previously we would withdraw 
those individuals and put them into withdrawal and then, 
depending upon the results of their trial, would be released 
back into the street, now in withdrawal, now sick and looking 
to use again and very vulnerable because their tolerance level 
has decreased. The number of overdoses in that population was 
significant.
    Providing them continued medication or, better yet, 
initiating the medication for individuals who needed it but 
didn't access it in the community provides that linkage after 
that brief period of incarceration to the treatment that's 
needed in the community, and the follow-up rates have been 
pretty successful. Seventy-five percent post-incarceration 
without perhaps the requirement of the criminal justice system 
that they do so is pretty remarkable, including the decrease in 
the overdose in that population that we have seen is incredible 
given the decreased tolerance that they had before, no longer 
that because they're on medication that has stabilized them, 
and a connection to treatment in the community, with the 
opportunity now for recovery. Perhaps that criminal justice 
intervention gave them that opportunity for recovery that they 
didn't capitalize on in the community.
    Senator Young. Well, thank you.
    Secretary Tilley, you're our southern neighbor, and you, no 
doubt, are experiencing very similar situations as we are. Can 
you speak a bit about any programs you have in place to get 
treatment to these incarcerated adults or those who are 
awaiting trial, get them into treatment in a better spot?
    Secretary Tilley. I think, first of all, I'm not proud to 
report that we've had to ramp up treatment in our prisons by 
that 1,100 percent mark. But what we've done to do that is 
we've collaborated and partnered with our community mental 
health centers to use intensive outpatient treatment upon 
release, because that handoff is often, again--it is the most 
critical time. We've done that.
    We are also, as I mentioned--the program we have that uses 
naltrexone, I didn't have a chance to expand on that. It's not 
just about the medically assisted component. There is also the 
holistic component of therapy and a social service clinician on 
the day that inmate leaves the prison, to lead them to 
resources in whatever community they're returning to; that's a 
really critical piece. We've gotten, again, great early numbers 
on that. We're trying to expand that. It is an expensive 
program, but it's certainly less expensive than the $24,000-a-
year cost of incarceration and all that comes with that--
societal strain, family strain, et cetera.
    Many other programs along those lines. The treatment of 
providers is coming in so fast to our state that that's one of 
the challenges, to make certain that we get them running as 
quickly as possible and at the same time not allow fly by-night 
providers. Only 1 percent of treatment right now is evidence 
based. That's a challenge for us.
    In the interest of time, the last program I might mention 
again to link people to treatment is this--we have a treatment 
hotline, but is this peer specialist bridge clinic, because 
those folks are going to end up in jails and prisons. Clearly, 
it happens more times than not. To link them to treatment 
before that criminal justice intervention is critical. Again, 
returns on investment and as a policy win and a public health 
win.
    Senator Young. Thank you, Mr. Secretary.
    A quick observation, Chairman, is that as we consider 
funding at the federal, state, and local level to address all 
these things, we're going to have to consider the costs of not 
doing something, the economic costs, and cost in social 
services and so forth. We're going to have to constantly keep 
that in mind, the cost of doing nothing or not doing enough.
    Thank you.
    The Chairman. Thank you very much, Senator Young.
    We have a lot of Senators here today, so I'm going to try 
to stick pretty close to the 5-minute limit so everyone will 
have a chance to ask questions.
    Senator Kaine.
    Senator Kaine. Thank you, Mr. Chair.
    Dr. Abubaker, my questions are mostly going to be directed 
to you. Talk about the over-prescription problem and the work 
that you're doing with prescribers. Many of us have worked on 
bills, some of which were included as part of the Comprehensive 
Addiction Recovery Act, to set up prescription guidelines 
around the co-prescription of naloxone, for example. On the 
Armed Services Committee, I've worked with colleagues there to 
deal with over-prescription issues within the VA and the DOD 
hospital system.
    But talk about your own work with especially folks in 
dentistry and your students and what more we can do to curb 
this over-prescription problem we have in the country.
    Dr. Abubaker. Thank you, Senator Kaine. I'll just step 
backward and relate it to prescription or over-prescription.
    I went through my dental school education, a good dental 
school in Pittsburgh, and went through my residency, and the 
emphasis on prescription or pain management was minimal, not 
only in dental school and residencies and dentistry but in 
medicine as well. Pain management is at the core of it, and 
what we train is really to write a prescription and walk away 
from the patient.
    That model ends up over-prescribing. There are patients who 
may need only two tablets, and there are patients who may need 
50 tablets. We have not had that kind of way of thinking. 
Prescription writing was a thoughtless, seamless process on the 
part of both physician and dentist, and that goes back to the 
lack of knowledge about pain management, acute pain management. 
I'm specifically talking about acute pain management.
    As a result, we standardized that you go to the oral 
surgeon for wisdom teeth, probably 20 tablets of Vicodin. You 
go to the orthopedic surgeon, they have a number, and 
neurosurgeons have numbers, and it's not standardized to the 
individual situation or an individual patient.
    Senator Kaine. The numbers themselves may not be science-or 
evidence-based at all.
    Dr. Abubaker. Absolutely. There is no science to it. 
Clearly, if there is a science, Patient A is not the same as 
Patient B, whatever way you look at it. As a result, that 
standardized number that we put in a prescription, it's not a 
scientific one. As a result, we end up over-prescribing for the 
most part.
    We looked at pain management as 100 percent prescription. 
We looked at prescriptions for the worst pain. We looked at 
prescriptions as the only treatment possible. We know now that 
for some other modalities, including non-pharmacological pain 
management, that it's good for some individuals but may not be 
good for others.
    The standardization of treatment is the key for this, and I 
think going back to the education factor--my business is the 
education business for the last 27 years--we have to go back to 
the basics. No. 1, pain management, the scientific basis of 
pain, the lack of standardization or the lack of evidence base, 
and going back to the risk associated with medication.
    I mentioned to you earlier that in some states now the 
regulation for prescribing includes mandatory discussion with 
the patient about the risks, possible complications, and how to 
dispense with the extra medication. Some people got 20 tablets, 
took 3 tablets, it sat in the cabinet and the grandchild 
grabbed it.
    The fundamental issues; we have to go back to the basics 
both in medical education, dental education, nursing education 
to be able to address the foundation, the root of the problem.
    Senator Kaine. You testified powerfully that this war on 
opioids really needs to be a war on addiction, and you have a 
clinic, the Motivate Clinic, which is designed really to go 
after the addiction problem. Tell us a little bit about that.
    Dr. Abubaker. The Motivate Clinic just started actually 
this year, and part of our legislative and our state effort to 
combat opioids and addiction in general. But the story used to 
be in an emergency room, when you come in with an overdose of 
any drug, you're treated for the overdose, admitted to the ICU, 
and when you live, they put you back on the street. God knows, 
maybe a week later, a month later, you come back with the same. 
There is no organized, systematic way of referring this patient 
to a specific treatment.
    VCU Medical Center developed a process. Now, when a patient 
comes in with an overdose, after treatment for the overdose, 
hopefully they survive the overdose, they automatically are 
referred to a clinic for follow-up and additional treatment 
down the line in the long term.
    Senator Kaine. This is a little bit like what Secretary 
Tilley was talking about in Louisville, the example that he was 
using.
    One last question, quickly. You also do work at VCU to help 
addicted pregnant moms break their addiction. Talk a little bit 
about that.
    Dr. Abubaker. Senator Kaine, clearly, the director of the 
Motivate Clinic is, by training, an Ob/Gyn.
    Senator Kaine. I see.
    Dr. Abubaker. He came from that side. He's a professional 
on that side, but he came into the side of addiction through 
pregnant women and children born addicted. That's his passion. 
That's his practice. There is a lot of it going on in our 
medical center.
    Senator Kaine. Great. Thank you for being here today.
    Dr. Abubaker. Thank you. My pleasure.
    The Chairman. Thank you, Senator Kaine.
    The Ranking Member, Senator Murray, is here.
    Senator Murray, I invited Senator Kaine to make opening 
remarks because you had another commitment. But if you have 
opening remarks you'd like to make, you're certainly welcome to 
make them.
    Senator Murray. Mr. Chairman, I just would like to thank 
you for having this hearing, and I won't delay. We have lots of 
folks who want to ask questions, so I'll submit it for the 
record. Again, thanks very much.

     [Opening Statement of Senator Murray Submitted for the Record]

    Senator Murray. Thank you, Chairman Alexander, thank you for your 
continued commitment to hold these bipartisan hearings on the opioid 
crisis.
    Needless to say, there's a whole lot going on right now in the U.S. 
Senate, and frankly, there's been a lot of strong disagreement and at 
times, very heated discussions around several issues.
    The so-called tax ``reform'' package being jammed through today, 
with yet another attack on families' health care, we have end of the 
year spending deadlines--you name it.
    But I hope we can all agree that the opioid crisis is an issue 
that, no matter what else is going on, cannot afford further inaction, 
as many have heard me say on this Committee.
    For the countless patients and families suffering from this 
epidemic, there is no tomorrow and there is no next time.
    It is absolutely critical that we make progress to address this 
truly devastating public health crisis--and that we do so in a 
bipartisan manner.
    I am pleased that we are joined today by a diverse group of 
witnesses, providers, public safety officials, and state health 
officials, who are on the front lines fighting this epidemic--and who 
can speak to what is going down on the ground and what more we in 
Congress can do to help them address this crisis.
    I am also interested in learning more about ways we can help bring 
communities together to prevent and combat addiction, and how that 
compares with what I am hearing back in my home State of Washington.
    Because, like everyone here, the opioid crisis is something I hear 
about every weekend I go back home.
    I've visited with countless communities that have just been 
devastated by addiction, this epidemic does not discriminate, it can 
reach anyone, and it can reach anywhere. I've listened to doctors who 
are treating skyrocketing numbers of babies born addicted to opioids--
parents who have lost sons and daughters, children who have lost moms 
and dads, to an overdose--and veterans with chronic pain who also 
struggle, each and every day, with addiction.
    The list, unfortunately, goes on and on. I will repeat this every 
time I can, this epidemic is not somebody else's problem. It's all of 
ours.
    Again, that's why I am very glad we have the opportunity today to 
discuss this further and to hear from those closest to the ground about 
what they are seeing.
    Now, right off the bat, it's clear to me there are steps we can 
take right now that would make a tremendous difference in this fight.
    We have seen increased public awareness around this crisis, we are 
learning more about addiction each day, but we continue to lack the 
increased investments and response needed from this Administration--
that would truly help states and communities address this complex 
challenge.
    As we all know, late last month, President Trump finally issued a 
memorandum to the Department of Health and Human Services and other 
agencies on the opioid crisis.
    I had hoped this announcement would bring about a much-needed 
change of course, and that President Trump would finally commit to 
supporting the substantial new investments that states, communities, 
and hospitals are making very clear they need to make progress on this 
crisis.
    Unfortunately, President Trump's attempt at appearing to take 
action did nothing to give states and communities the resources they so 
desperately need, and in fact suggested that this problem could be 
addressed by using funding for other public health priorities, which 
underestimates the needs in all these areas. This was deeply 
disappointing.
    Unfortunately, it represents a pattern of tough talk, no action 
that we've seen time and again from this Administration. And just to 
further underscore how inadequate this Administration's response to the 
opioid crisis has been--earlier this month, the White House's own 
Council of Economic Advisors released a report estimating the economic 
cost of the opioid crisis to be at over $500 billion dollars, just for 
2015.
    That is six times larger than the most recently estimated economic 
cost of the opioid epidemic. So we desperately need this Administration 
to be a partner in fighting this epidemic.
    But unfortunately what we continue to see is simply not enough. 
Congress has taken some steps, thanks to our bipartisan efforts on this 
Committee, to address the opioid crisis.
    Like everyone here, I am proud of our work to pass the 21st Century 
Cures Act, which included nearly $1 billion for states to address the 
opioid crisis through: prevention, treatment, and recovery efforts.
    CARA, the Comprehensive Addiction and Recovery Act, which supports 
specific outreach for veterans and pregnant and postpartum women 
suffering from addiction, and expands access to medication assisted 
treatment.
    These were important steps, no doubt about it, but we can and must 
do more. As we continue to consider further action, I am committed to 
ensuring we have strong congressional oversight over Cures and CARA so 
they have the intended benefits and impact for patients and families.
    There's a whole lot more to discuss, but I would also like to make 
sure we leave as much time as possible for questions.
    I would just again thank you Chairman Alexander, and all our 
colleagues for their continued efforts to tackle this pressing 
challenge.
    I know there are many efforts being spearheaded by our colleagues 
on this Committee that would make progress and build upon our work thus 
far. I hope our discussion today can better inform and add to all those 
efforts.
    Thank you again to our witnesses, I look forward to your testimony.
                                 ______
                                 
    The Chairman. Thank you, Senator Murray.
    Senator Baldwin, Senator Whitehouse, you both have 
witnesses here. I've introduced them, but if you'd like to say 
another word about them now before we go to Senator Paul, 
you're welcome to do that.
    Senator Baldwin.
    Senator Baldwin. You can go first.

                    Statement of Senator Whitehouse

    Senator Whitehouse. Well, I just want to welcome Rebecca 
Boss here, who is the Director of our Department of the 
unfortunately named Behavioral Healthcare, Developmental 
Disabilities and Hospitals. But we call it BHDDH. She has been 
working to serve those struggling with addiction for more than 
25 years, working as a clinical supervisor and program director 
before joining the Department in 2004. She became the Acting 
Director in 2016 and was confirmed as Director this May.
    Director Boss helps ensure that Rhode Islanders facing 
addiction and other behavioral health issues have access to 
high-quality prevention, treatment, and recovery services. She 
was very active at meetings and roundtables I held while 
drafting the Comprehensive Addiction and Recovery Act, and was 
integral in developing Rhode Island's Overdose Prevention and 
Intervention Task Force Action Plan. She has received state and 
national recognition for her work on developing and 
implementing AnchorED, a program that connects overdose 
patients in emergency rooms to peer recovery coaches.
    Director Boss studied psychology at the University of Rhode 
Island, and received her Master's Degree in Counseling and 
Educational Psychology from Rhode Island College. Rhode Island 
is very proud of her.
    Thank you for coming here today.
    Thank you, Chairman.
    The Chairman. Thank you, Senator Whitehouse.
    Senator Baldwin.

                      Statement of Senator Baldwin

    Senator Baldwin. Well, thank you for this opportunity, Mr. 
Chairman. I am thrilled to welcome Dr. Andrea Magermans to the 
Committee.
    I know you've been introduced, but I'm particularly 
thrilled because I really think Wisconsin is leading the Nation 
with its new Enhanced Prescription Drug Monitoring Program, the 
ePDMP. It's a mouthful, but it is truly a state-of-the-art 
system. Not only is it a reporting tool, but it is also a 
prescribing assessment, public health and communication tool, 
and it's able to integrate directly into the medical record.
    More than 48 million prescription records have been 
submitted to the PDMP, and it's helped contribute to an over 11 
million decrease in the number of opioid doses dispensed. 
Importantly, this system was developed with end users and 
providers themselves to make sure that it works for them.
    I am really proud of this innovative tool and the work that 
you've done, your long-term experience in the State of 
Wisconsin. We know that this tool is critical to our fight 
against the opioid epidemic.
    Welcome to the Committee, and thank you for sharing 
Wisconsin's story with our panel.
    The Chairman. Thank you, Senator Baldwin.
    Now to continue with our round of questions, Senator Paul.
    Senator Paul. You know, as a physician, it pains me to 
acknowledge that I think a big part of the problem is physician 
prescribing habits. I think those were also influenced by some 
misinformation from the drug companies on the idea that 
OxyContin wasn't that addictive. It turned out to be maybe just 
a little bit untrue.
    I think that when we look at prescribing habits and we look 
at changing, we've been talking about this, and in Kentucky 
we've done some good things. We closed down some of the pill 
mills. We got rid of some of the checking prescriptions to make 
sure people weren't doctor shopping and duplicating. But we 
still have a county that has 21,000 people in it that had 2.8 
million doses of OxyContin prescribed, OxyContin and Percocet. 
I lump them all together. That's 150 doses for every person who 
lives in the county.
    Something is wrong, and we think we've gotten rid of the 
worst doctors that were out there doing it, and this still 
occurs. Something is wrong in our habits. From when I went to 
medical school, this is sort of the conundrum. Doctors don't 
want people to hurt, you know? I recently was the victim of an 
assault and had six ribs broken, and I was given opioids of 
some sort, and I finally made the decision just not to take 
them, not because I was worried that I would be addicted, 
although I was going to need four to 6 weeks of them, but I 
took large doses of Ibuprofen. People are, like, oh well, 
Ibuprofen is Advil, that's no good. Well, it does control pain. 
I still had a lot of pain, but I did get some relief with 
Ibuprofen. People think that's not good enough because it's not 
a narcotic, and I just don't think we've studied these things.
    There is an evidence base in medicine on a lot of this to 
know. It reminds me of my wife when she was having a baby. They 
gave her morphine. She said, well, I was drunk as hell, but I 
still hurt like hell. You know, it affected her sensorium but 
it didn't cover her pain. She liked the Epidril a lot better, 
to tell you the truth.
    There are ways to control pain, but I think we have made a 
mistake in over-prescribing. They say that four out of five 
heroin users started with prescription medication. Certain 
people are probably more prone to addiction than others, but 
they got on it, they got hooked, and then they somehow switched 
to heroin.
    I guess my question for Secretary Tilley is we cut down the 
pill mills, we're cutting down duplicate, but we still have 
this massive prescription of pain medications, and when I talk 
to the doctors they say, well, they've been on it forever, and 
they're on four. They are tolerating it. A lot of them are just 
addicted and they're tolerating three or four and they're not 
dying from it, but it's still not a great life.
    We've got to figure out a way--some of it should maybe come 
from the medical community, that we need to change what our 
recommendations are and how we practice. But do you have a 
recommendation, Secretary Tilley, on what we've done so far and 
why we still have counties with 2.8 million doses of opioids 
being prescribed?
    Secretary Tilley. Senator, yes. I was going to mention the 
same county and those same numbers that I shared with Andrea to 
my right.
    First thing, Kentucky is the first state to mandate the use 
of a PDMP. I think Castro was one of the first in the country 
to do that.
    Second, we were the first state in the country to limit 
based on CDC recommendations. Just this past legislative 
session, the Governor dug his heels in on this. It was not easy 
to limit the prescription of opioids for acute pain to 3 days, 
because the CDC says between three and 5 days addiction begins. 
We're the first state to do that. You've got to shrink the size 
of the funnel at the top to keep these opioid dosages from 
coming into communities, and that's the first step in that 
regard.
    To your point, too, again, I mentioned the book Dreamland 
only because I think I'm compelled to do it for the notion that 
I think we were sold a bill of goods, and I'll leave it at 
that. I think physicians were sold a bill of goods. After 
understanding what morphine can do to people in the day, and 
now moving forward into the `90's, what is chronicled in this 
book should be read by everyone who has a concern for this 
problem.
    That said, at the University of Kentucky there is a new 
protocol to do just what you said, and that's begin with 
everything but an opioid rather than the opposite. Why begin 
with a narcotic? Begin with everything to deal with pain, the 
narcotic being the absolute last resort, and in a controlled 
setting a narcotic can be effective. It can't be diverted, 
potentially. That's why the injectables are coming online.
    At UK, there are two patents pending. One is for injectable 
buprenorphine, but that's a little off, but that's non-
convertible. It can deal with the addiction. The second is a 
mist for naloxone. But again just to say the kind of innovation 
in the medical community I think answers your question.
    Senator Paul. Here's one quick suggestion. As physicians, 
we don't want to be told what to do too much, and people need 
pain medications, and some physicians fear it will be too 
controlled and people will suffer with pain. But one of the 
things you might consider--and I don't know if you've done 
this--is go to the head of the medical society or the state 
board and have them go to these counties and just have a 
meeting with the medical society of 10 or 20 doctors and let 
them know these are your statistics and that you are outside 
the parameters, not put people in jail but let people know, 
because I think somehow there could be some sort of persuasion 
maybe within the medical community, even stronger than just 
universities. Universities probably aren't as big a part of the 
problem as communities are where people are decades-long 
addicted, you know?
    Secretary Tilley. If I could, Chairman, just quickly on 
that point, I would credit the medical community nationally but 
also in Kentucky for recognizing that the posture was so 
defensive 5 years ago when we began trying to legislate our way 
out of this to a certain extent, and today it's much different. 
We have done just what you suggested, and I think it's an 
excellent suggestion. We need to do more of that, and that's 
why you see the medical schools now upping their training 
requirements for prescribing practices for opioids, as an 
example.
    The Chairman. Thank you very much, Senator Paul.
    Senator Bennet.
    Senator Bennet. Thank you, Mr. Chairman.
    I would join Secretary Tilley in recommending Sam Quinones' 
book about this. When you finish Dreamland, you really have to 
ask yourself what we're doing here as a country. I mean, 50,000 
people a year are now dying, and we really haven't responded.
    In my state, in Colorado, especially in rural parts of the 
state, although it really is everywhere, but in rural parts of 
the state there is no more access to addiction treatment today 
than there was 10 years ago when this started, none. If you go 
to the San Luis Valley and have a town hall, you'll have three 
or four questions today, but 6 years ago, 7 years ago, nothing, 
and there is still no additional addiction treatment, except 
for what's happening in the jails, and I'm going to come to 
that.
    I want to ask Director Boss a question first. Today's 
Denver Post reports that we have had an increase in Colorado of 
newborns addicted to opioids that's 80 percent between 2010 and 
2015. I can only imagine that number is worse in 2017. In some 
parts of Colorado, the rate is even higher. Parkview Medical 
Center in Pueblo, the city's safety-net hospital that sees many 
Medicaid patients, the rate of newborns addicted to opioids 
skyrocketed from 0.7 per 1,000 people in 2010 to 20.8 per 1,000 
people in 2012. The rate now hovers around 10, and doctors have 
noted a shift from prescription drugs such as OxyContin to 
street drugs, mainly heroin, in recent years. I'm quoting from 
this Denver Post article.
    The article went on to state that the number-one cause of 
death for pregnant women and new mothers in Colorado is drug 
overdose. I wonder, based on your work in Rhode Island, what we 
should be thinking about in Colorado and other places when it 
comes to caring for mothers that are addicted and their 
newborns who are addicted.
    Ms. Boss. Thank you, Senator Bennet. I do know that we are 
seeing an increase in the number of women who are overdosing as 
a result of opioids, and that fact can't be forgotten in terms 
of the importance of the addiction on the family and, as you 
mentioned, on the newborns. We are seeing an increase in 
neonatal abstinence syndrome. We have a workforce in Rhode 
Island that is addressing that issue.
    It's important to remember that infants aren't born 
addicted, which implies behavior. They're born dependent on a 
substance, and there is medical treatment for that condition 
when they're born dependent on a substance, and the use of 
medications, which can be methadone or buprenorphine, may also 
increase those born, but those are the treatments that are 
recommended.
    It's important as we look at the increase, it may reflect 
an increase of individuals who are being appropriately treated 
with medications for their addiction, and the care of the 
infants is really important.
    One of the things that has come through in the last few 
years, through Congress, has been an increase in PPW funds, and 
I think that the Pregnant Postpartum Woman funding for 
treatment is critical. If we look at programs that are 
effective in addressing women, we have to provide funding for 
programs that will treat the children of these women as well. 
Addiction affects the entire family. When women are adequately 
supported and given the tools for recovery, they recover. The 
importance is providing the funding for that, and I appreciate 
the work that's been done thus far, and I look forward to our 
work going forward and providing more support to those 
individuals.
    Senator Bennet. But, Secretary Tilley, at the last hearing 
we had on the opioid crisis I asked what we could do to help 
people struggling with prescription drugs or heroin addiction 
that have lost their Medicaid coverage because they've been 
placed in jail. Colorado counties especially, again, are rural 
areas and struggle to find money for addiction treatment and 
care, and management for inmates who are cutoff from Medicaid. 
There is agreement from the witnesses that a jail is a pretty 
lousy place to administer addiction treatment. I know, partly 
because I read that book, that Kentucky has done some important 
things here, and I wonder whether you'd be willing to share 
that in the last minute or so that we have.
    Secretary Tilley. I will, and certainly I thank you for 
that. A suspension of Medicaid so that it doesn't take as much 
red tape to get it going again on release of that inmate is 
critical, so that's something I would consider.
    The use of social service clinicians. Again, social 
workers, immediately upon release, to link that inmate right 
back to whatever resource they need.
    I would also say that access doesn't always equal outcomes. 
Certainly we need money at every turn for treatment, but there 
certainly are ways to be innovative, and there are ways to use 
that money in targeted and surgical ways to set up just the 
kind of outcome-based interventions that can work for those who 
are leaving prison or jail.
    I am one who also thinks that the best kind of treatment 
does not occur. It's absolutely essential to have it behind the 
walls of prisons or jails. But the best kind of treatment 
doesn't always occur there. That's why the use of sometimes 
controversial civil commitments in Kentucky--we call it Casey's 
Law, Senator, after a young man, Casey Wethington, died of an 
overdose years ago. We've had some trouble expanding that. It 
works, but it could work better.
    To use civil commitments would then preserve whatever 
benefits, like Medicaid, that individual may have in a civil 
setting, as opposed to an incarceration where they would lose 
those benefits.
    You've touched on something very critical, and again, we 
just try to link people back to it as quickly as possible. 
We're also trying to release people into treatment facilities 
with some parole practices that are unique. We're working on 
those today so that we identify those. What we found is 
incredible.
    The Chairman. You're over the 5 minutes.
    Secretary Tilley. We found we have far too many people with 
possession-only offenses in prison. That's a shocker, I know, 
but it's not better than it was 10 years ago.
    Senator Bennet. Thank you.
    The Chairman. Thank you, Senator Bennet.
    Senator Isakson.
    Senator Isakson. Thank you, Mr. Chairman.
    I want to commend Dr. Abubaker and all of you for 
testifying today. It's a very important hearing. In fact, it's 
probably the most important hearing from an educational 
standpoint that we could possibly have, and I thank Chairman 
Alexander for calling it.
    I want to get everybody to look at this, the next-to-last 
paragraph of Dr. Abubaker's prepared remarks. It's in your 
book. I want to read two things in there that are critically 
important, and I want to tell you why.
    Dr. Abubaker says, ``I'm worried we will not address the 
root of the current opioid epidemic, which are addiction and 
mental illness as the underlying reasons for all drug epidemics 
we have been through and face in the future. If we do not 
address the foundation of these epidemics, I fear that another 
drug epidemic will emerge from now, and another generation of 
Americans, maybe even our own grandchildren, will be faced with 
a drug crisis of a different kind. We had better not let this 
happen. With the knowledge we have now about brain function and 
how addiction affects it, to let future generations of 
Americans be affected by similar crises in the future would be 
a historical abdication of our responsibility to do good for 
our country.''
    That is a powerful paragraph. It's powerful to me because I 
lost my grandson, Charlie, December 8th of last year to a drug 
overdose. Charlie would be the first person to tell you, if you 
can cure the addiction problem, not the pain problem but the 
addiction disease, that probably wouldn't have happened. I miss 
Charlie to this day, and I have always sworn that I'm going to 
use that loss when I can to help, as you did today in your 
testimony.
    Others understand that those tragedies don't just happen to 
other people, they happen to us. They can happen to us.
    Second, I had a unique experience this year. I had two 
major back surgeries, one in February and one in March. I 
learned a whole lot of about OxyContin and hydrocodone and lots 
of things I didn't know anything about that I thought were just 
pills to make me feel better. But the ramifications and the 
potential amplifications of taking those medicines at the age 
of 72 for pain can get you in a whole lot of trouble.
    I remember when my surgeon had me interview with a mental 
health specialist before the operation to talk about what the 
anesthesiologist was going to recommend to me as a pain 
management regimen. I knew this must be a pretty big issue. 
It's not like taking an aspirin.
    I think your testimony is powerful in what we all can do. 
One is to try to better educate the educational establishment 
of physicians and providers to the role they have in limiting 
the exposure people will ever have to these opioids, and 
hopefully depending on other ways of treating pain that avoid 
it entirely. With both of my surgeries--and I'm not trying to 
sell a product here, but Tylenol was my pain management 
medicine of choice. I would have never thought that going in 
for the operation, but realizing what happened to Charlie and 
his overdose with an opioid last year, I realized how that 
counseling saved me and helped me a lot in mine.
    I want to thank you for your willingness to testify about 
your own personal experience. But I do think you're right, the 
mental health aspect and the addiction disease are the things 
we really ought to focus on as a Committee and as a country. If 
we don't, there's a worse price to pay later on in another 
generation. We don't know what that price will be, but we know 
it's there if we don't deal with this now.
    I just want to thank you for your testimony.
    I thank you, Mr. Chairman, for bringing this to everybody's 
attention, and I'll yield back my time.
    The Chairman. Thank you, Senator Isakson.
    Senator Franken.
    Senator Franken. Thank you, Mr. Chairman, for this hearing.
    Dr. Abubaker, I'm sorry I wasn't here for your testimony, 
but I read it last night, and I was very moved by all your 
testimony and describing the tragic death of your son, how it 
motivates your work.
    In your testimony you note that the problem is not solely 
opioids and that we need to move the conversation to dealing 
with addiction as a disease of the brain, and I agree 100 
percent, and I appreciate the work you're doing to educate 
medical and dental students on appropriate prescribing 
practices of opioids.
    I firmly believe that all clinicians need this training. 
That's why, as part of the 21st Century Cures Act, Senator 
Cassidy and I championed a provision to grant funding to 
improve training for medical schools and medical students and 
dental students and practitioners and nursing students and 
practitioners and social workers.
    Our Nation's clinicians need to know when they see someone 
who has an addiction problem, and I don't think they get that 
training. They don't get that training in medical school. They 
don't get that training, and we need to have that training. 
That was the purpose of that.
    Dr. Abubaker, the CDC recently released prescribing 
guidelines for medical providers who are prescribing opioids 
for chronic pain. How will these guidelines help change opioid 
prescribing practices?
    Dr. Abubaker. Thank you, Senator. In my profession and 
specialty, oral surgery, the major emphasis for our training 
for students or residents is acute pain. There are a few 
instances where we deal with chronic pain, something called 
TMJ, if you've heard of it. That usually turns into chronic 
pain. The guidelines in general, in principle, for the 
management of acute and chronic pain is compassion for the 
patient's need. Historically, we thought the compassion equaled 
the number of tablets or the strength of the medications.
    I think we have to go back to compassion as what hurts and 
what harms the patient and what benefits the patient. Sometimes 
the non-pharmacological management for acute pain--and I'm not 
a specialist, so I have to explain that I have no expertise in 
chronic pain. But from my perspective, the compassion for the 
patient, some patients will need opioids, long-term opioids, 
but we have to individualize the treatment.
    Also, we offer tailored treatment to the individual, for 
some people spiritual or maybe some other non-pharmacological 
agent, sometimes mild pharmacological agents. But clearly, the 
bottom line is the scientific basis and the evidence-based 
management. I think the CDC recommended that kind of guideline.
    Senator Franken. Senator Isakson read the last paragraph 
and talking about this as a disease of the brain and being 
resilient for the next addiction crisis. I think this is one of 
the reasons that we have to fund NIH funding and mapping the 
brain. I think that's so important.
    I have so much to ask about. I hope we'll be able to get a 
second round.
    Ms. Boss, I was so impressed by what you put together in 
Rhode Island, and I certainly hope that is being studied and 
copied, the Anchor MORE Program, the coaches, the recovery 
coaches. What I was really interested in was how they seem to 
be everywhere and how you trained them up, and how you made 
sure that--Senator Bennet talked about how there's not enough 
treatment. We need more treatment, and we need more counselors.
    One of the problems in my state is Indian Country. I'm 
going to try to get done before my time runs out so you can 
answer the question of how you did this. But in Indian Country, 
when they say culturally specific, many times that means an 
Indian provider.
    How did you train all these people? How did that happen?
    Ms. Boss. We have specific training for our recovery 
coaches, and they actually go through a certification process. 
But for those that are dealing with individuals who are high 
risk, we enhance that training even more. The Anchor MORE 
outreach counselors that go to data-identified hot spots where 
there's increased activity with overdose or fentanyl in the 
area, they are specifically trained to distribute naloxone, 
teach people how to use naloxone. They're specifically trained 
to motivate people to want treatment. This is where we need to 
identify. We have treatment available. We have to get the 
people to that treatment. Sometimes, in providing the hope of 
recovery, I've done it, I've been where you are, I know what 
you're going through, life can get better.
    Often times, when people are in the midst of their 
addiction, they don't see that opportunity to get better. 
Recovery coaches who have been there are able to provide that 
spark of inspiration that there might be an opportunity for my 
life to get better. They're actually going out into the 
community to find these folks, not waiting for them to overdose 
and show up in the ED.
    The Chairman. We're running out of time.
    Ms. Boss. Thank you.
    Senator Franken. Thank you.
    The Chairman. I'm going to--we all have important 
questions. We have 10 Senators who haven't had a chance to ask 
questions yet, I'm going to keep a pretty strict rule on the 5 
minutes for questions and answers, if everyone would respect 
that, my colleagues.
    Senator Cassidy.
    Senator Cassidy. Thank you. Thank you all for what you do.
    Ms. Magermans, I really like your PDMP, and I'm asking 
questions not to diminish but to understand. It seems like you 
are a model for what everybody should be doing. But when I look 
at the number of opioid deaths in HIV from your Wisconsin DPH, 
you've actually increased since implementation. I say that not 
to accuse but to understand. Why, with such an incredibly 
effective program since 2013, have opioid deaths risen from 350 
to 400, that sort of thing?
    Ms. Magermans. Thank you, Senator. I think we can see that 
there is a reduction in the opioids that are being prescribed 
and dispensed. However, there is an increase in overdose 
deaths, and I think it's because of the presence of the 
fentanyl and the fact that there are heroin overdose deaths 
with----
    Senator Cassidy. Let me ask, because I'm looking at these 
stats--I can share this, but it's from your government.
    Ms. Magermans. Sure.
    Senator Cassidy. The prescription opioids are also up 
sloping. It's the heroin, but also prescription opioids. So, 
any thoughts about that?
    Ms. Magermans. I think it's a slow process. I think that 
the prescribing has effects later on down the road. Reduced 
prescribing, there are people who are already addicted and who 
may end up overdosing, and I think it's really just moving in a 
new direction once you do start curbing some of the 
prescribing. I think the effects will be later.
    Senator Cassidy. A lag time before effect.
    Ms. Magermans. Exactly.
    Senator Cassidy. What do you do with your data? Do you 
proactively refer--you implied you did, but to confirm, do you 
proactively refer a physician who is an outlier, three standard 
deviations out? Do you proactively refer she or he to law 
enforcement?
    Ms. Magermans. To law enforcement? No. The Controlled 
Substances Board oversees the program in Wisconsin, and the 
Controlled Substances Board has the authority to refer to the 
licensing board, a physician to the medical board, an advanced 
practice nurse prescriber to the nursing board, et cetera.
    Senator Cassidy. There is a pattern of physicians that are 
pill mill doctors. They move from state to state to state to 
state. I say that as a physician; and, as Dr. Paul said, 
regretfully so.
    Is there any way to track a risk factor for a doc being a 
pill mill doc? I see Secretary Tilley nodding his head, so I'd 
love to have your input as well. My gosh, licensing board, he's 
lost his license in three other states. It seems like there 
should be a trigger for someone to monitor.
    By the way, I'll tell you, I once had a drug rep come up, 
and she said I know who the pill mills are, because I can go to 
their office and there's a certain clientele. Somebody pays 
$300 for an initial visit, and they walk out with a handful of 
prescriptions 5 minutes after entering the exam room. I'm 
thinking, a drug rep can figure this out. Not to diminish her, 
but she's just observing, and everybody with their data bases 
aren't coming to the same conclusions. Hats off to her, but 
it's a little bit indicting us.
    Any thoughts on that?
    Ms. Magermans. Speaking of the Wisconsin PDMP, the data is 
about prescriptions that are dispensed in Wisconsin. A 
prescriber that first practiced outside of Wisconsin would not 
have PDMP data that is analyzed with the Wisconsin PDMP data. 
However, things like the average distance that patients travel 
to see a----
    Senator Cassidy. I don't mean to cut you off. I just have a 
minute 38 seconds.
    Secretary Tilley, you were also nodding your head when I 
spoke about these pill mill docs. Any thoughts on that?
    Secretary Tilley. Yes, a number. But in a minute I would 
tell you very briefly that we are tracking that data. A company 
is helping a number of states do that as well, red flagging, 
letting doctors know where they stand as well, so they can look 
and see. They are often getting busy, not understanding how 
many they may be prescribing, seeing some of those red flags 
themselves to be able to self-assess.
    Senator Cassidy. If a doctor is going from Indiana to Ohio 
to Tennessee to your state, and somehow there have been flags 
along the way that the doc is a pill mill doc, would you know 
that?
    Secretary Tilley. We would. There's only one state we can't 
collaborate with now. Of the seven border states of Kentucky, 
Missouri is the only one where we're trying to get there. Not 
to be critical, but it's the reality. But we do know that. We 
can track that.
    Senator Cassidy. Okay. Does that affect the licensing of 
that physician to obtain a medical license and/or the 
surveillance of his practice once you so identify?
    Secretary Tilley. One of the challenges has been the Board 
of Medical Licensure in our state. They have come a great ways 
in that area, but I still think they need to be more aggressive 
in making certain that docs who are over-prescribing, No. 1, 
know it and have a chance to correct it, and if they don't, are 
sanctioned for it.
    Senator Cassidy. Next, Ms. Boss, I have a few seconds left. 
You mentioned in your testimony giving MAT to people in prison. 
Did you mean jail? In other words, short-term imprisonment? Or 
did you mean prison? In other words, they're going to be there 
for 10 years?
    Ms. Boss. I meant both.
    Senator Cassidy. If they're in prison, there for 10 years, 
you must have a problem with contraband?
    Ms. Boss. The program has been in effect for about a year, 
and we have not, as far as I understand, not seen an increase 
in contraband. Now, please know that we don't provide MAT for 
an individual who has a sentence of 10 years until prior to 
release. If someone has a history of opioid dependence and 
they're leaving and they are at risk for overdose and are 
appropriate for medication and want to get on medication, we 
are willing to provide that medication prior to release, but 
not for a 10-year sentence.
    Senator Cassidy. I'll finish by thanking you, Dr. Abubaker, 
for your powerful testimony.
    I yield back.
    The Chairman. Thank you, Senator Cassidy.
    Senator Murphy.
    Senator Murphy. Thank you very much, Mr. Chairman.
    Thank you all for being here. We have other hearings; we're 
in and out. But this has been very, very helpful.
    I have a few questions. I'll just start by noting that it's 
very hard to confront this epidemic when we are threatening to 
pass health care legislation that would remove $800 billion 
from Medicaid, which is the program that ends up treating 40 
percent of addiction clients in this country. We're about to 
vote on a piece of legislation later tonight that would trigger 
automatic cuts, in the neighborhood of $25 billion, to 
Medicare, $1.7 billion in the first year alone to the social 
services block grant. I think this is all really, really 
important and helpful, but we're going to make your life a lot 
harder if the legislation that has been pending throughout the 
year becomes the law.
    Ms. Boss, I wanted to follow-up on your testimony 
mentioning Rhode Island's efforts in promoting non-opioid 
therapies for chronic pain. Senator Paul asked a little bit 
about this, and I'd be happy to hear others' testimony on the 
panel to this question. But can you just talk a little bit 
about what the barriers are today to getting non-opioid, non-
drug-based therapies for pain? Amongst them that I've heard is 
insurance companies making it a lot easier to get reimbursement 
for a drug than it is for physical therapy or acupuncture, the 
lack of providers in this space if you try to find alternative 
pain therapies.
    I'd be happy to hear others' testimony, but you raised it 
in your prepared remarks, so let me pose it to you first.
    Ms. Boss. Thank you. Our efforts to combat this epidemic 
are really in four areas, the first being prevention. We've 
done a lot of work in terms of trying to reduce the supply of 
opioids and the prescribing of opioids and making sure that 
they're appropriate. A lot of the work that's been described 
previously has been done in Rhode Island as well.
    One of the things that we focused on, and our Department of 
Health is very active in working with the medical community to 
look at alternative pain management therapies, and the work of 
our legislature, and the work of our insurance company and 
Office of Health Insurance commissioner to make sure that there 
is adequate coverage for alternative pain management therapies.
    Things like massage, things like acupuncture, things like 
chiropractic are important in combatting the pain that 
individuals suffer without opioids. We've done a lot of work 
engaging multiple stakeholders in making sure that the 
insurance companies around the table, they have a seat at the 
Governor's Overdose and Intervention Prevention Task Force, and 
making sure that our legislators are on board in terms of 
promoting insurance coverage for alternative pain management 
therapies. That's really where the importance is.
    We haven't seen, to my knowledge, a lack of capacity within 
that provider system. It's really about whether or not people 
can afford it, and people can afford it generally if their 
insurance coverage is going to cover it.
    Senator Murphy. How are we doing on that? I mean, you're 
working on it, but do you see insurance benefits today covering 
the range of alternative pain therapies that should be covered?
    Ms. Boss. I believe that we are making progress. I can't 
say that 100 percent of all insurance in Rhode Island covering 
the alternative pain management therapies is as much as we 
would like to see, but I think that we have made progress and 
that those pain management therapies are being covered by most 
insurance.
    Senator Murphy. Secretary Tilley, do you have anything to 
add?
    Secretary Tilley. It's a challenge for us. We have a system 
of managed care. We are trying to work with those providers, do 
master agreements with them to cover. The challenge is 
certainly sometimes the companies don't see that individual as 
a long-term health concern for them, so the immediate need is 
to cut pain at less cost rather than to improve their lifestyle 
through physical therapy, through nerve blocks. You mentioned 
all the others, so I won't repeat them.
    That is the way to partially get us out of the need for so 
much pain medication, even if it is a Tylenol, which certainly 
is much less problematic than the narcotics we're discussing 
today.
    Yes, the challenges are great. Again, my umbrella in the 
justice cabinet is pretty broad, from corrections to public 
defenders to everything in-between under the umbrella of 
justice, but we are working daily in justice because this 
problem is so pervasive in the criminal justice system with 
public health, with the health and family services branch, with 
the insurance companies on these issues to try to get them to 
come to the table.
    I can't possibly finish that in 27 seconds, but you've hit 
a nerve, let's just say that.
    Senator Murphy. Maybe there's not legislation on this, Mr. 
Chairman, but just potentially the opportunity to use a 
bipartisan bully pulpit to make clear to the insurance 
companies that this is in their best interest to ultimately pay 
for these alternative therapies. It might cost a little bit 
more money up front than the bottle of pills, but in the long 
run it's going to save you an enormous amount of money.
    Thank you, Mr. Chairman.
    The Chairman. Thanks, Senator Murphy.
    Senator Murkowski.
    Senator Murkowski. Thank you, Mr. Chairman. Thank you to 
each of you this morning. We truly appreciate your testimony, 
your work, and just the effort to deal with this epidemic, 
pandemic, as we have been describing it.
    Senator Bennet mentioned that so much of the challenge in 
many of our states is the rural aspect. It may be that you can 
get coverage for treatments, but if you can't get to the 
treatment, it's pretty difficult.
    Ms. Boss, you acknowledge in your recommendations that many 
individuals living with substance abuse disorders don't have 
access to transportation. You just can't even get there.
    One of the things that we've been working on in Alaska, 
because again we simply don't have sufficient treatment that is 
available, and the distances are limiting, the FDA has just 
recently approved a device that's called the bridge device. 
We've been working in certain areas to--it's an ambulatory 
detox model, and through the use of the bridge device, which 
reduces the symptoms of those who are going through withdrawal, 
along with medically assisted technologies, the MAT, using 
Vivitrol and counseling, we have been trying to use this as 
this effort to fill the gaps until we're able to get more 
treatment facilities that are online. We've got the potential 
for additional facilities, additional beds coming on, but it 
may be 2 years from now, maybe even longer than that. As we all 
know, none of these individuals have 2 years to wait.
    Being able to share some of the pilots that are going on in 
different areas, particularly as we're struggling with how we 
deal with the realities of rural restrictions, things that 
limit us from any level of treatment whatsoever. I will note 
that in our state, the benefit that has come to us in being 
able to treat more through Medicaid expansion has been quite 
significant for us as a state.
    I wanted to ask a question that, Secretary Tilley, you 
reference in your written testimony but you just kind of 
skirted by it, and that is the issue that we're beginning to 
see with outbreak of HIV or hepatitis because of the needles 
that are being used to inject heroin. I'm actually going to be 
meeting with a member of our state health and social services 
department with a specific focus to the syringe services 
program that we are trying to implement in the State of Alaska.
    Can you, or if others have more information on this--
because we're dealing with an opioid epidemic. But again, are 
we also leading ourselves to a hepatitis epidemic, a resurgence 
of HIV? Can you please speak to this?
    Secretary Tilley. Yes, Senator, I absolutely can. In 
Kentucky we became the first southern state 2 years ago to 
legislate a comprehensive statewide program, very 
controversial. Again, I think people thought I had three heads 
when I stood up on the House floor when I was in the 
legislature to talk about it for the first time. I did that, 
and now we have 41 programs in a state, again, that is in 
desperate need of this because our Hep C rates are seven times 
the national average, our HIV rates are off the charts. Of the 
220 counties most susceptible, according to the CDC, of a rapid 
HIV outbreak, 54 of those counties are in Kentucky.
    The Senator from Indiana mentioned the problem. I'm right 
across the river from Louisville. It happened in Austin, 
Indiana, many of you know by now, with rates of HIV and their 
outbreak like that of Sub-Saharan Africa. That was instructive 
to us on how close we were to that kind of public health 
nightmare. We're proud of this effort now to move forward on 
that.
    I would say as it relates to corrections, we don't treat 
now without symptomology. If there would be some requirement to 
do that--and this applies to many states around the country 
moving forward--I don't know how the existing tax base could 
withstand an additional $100 million burden to treat for Hep C 
on the front end without symptomology, which again we can do 
today.
    Again, to say you've hit a nerve, you absolutely have. 
Anything we can do in the public health arena to cut down the 
blood-borne illnesses is critical to this entire problem.
    Senator Murkowski. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Thank you, Senator Murkowski.
    Senator Hassan.
    Senator Hassan. Well, thank you, Mr. Chairman, and Ranking 
Member, for having this hearing. Thank you and good morning to 
all of our panelists.
    Dr. Abubaker, thank you so much for speaking up. I also 
want to thank Senator Isakson for talking about his grandson.
    I was Governor of New Hampshire before I took on this role, 
and so I've been dealing with the opioid epidemic in my home 
state, where it is absolutely devastating, since 2013, and I 
have to start by saying that if this were any other kind of 
public health crisis that was taking 100 lives a day, which is 
about what the opioid overdose death rate is right now, if this 
many people were dying in a defective plane every day in the 
United States of America, we would be devoting considerably 
more resources to it.
    Part of the reason we haven't is because of the stigma that 
has traditionally come with addiction. So, doctor, your 
speaking up about your son, Senator Isakson speaking up about 
his grandson, the people in this room, and I know there are 
many, who have lost loved ones or who have struggled with 
addiction themselves speaking up about it is critical to this.
    We need a long-term strategy to solve this complex problem, 
and that requires funding to support those on the front line of 
the crisis. The Trump administration has so far refused to 
request additional funding to fight this crisis, and yesterday 
I pressed the HHS Secretary nominee on the issue because we 
need the Administration to send to Congress a supplemental 
funding request so that we can appropriate more funds and 
resources.
    For each witness here, I just would like a yes or no 
answer: Do you think additional funding is necessary? I'll 
start with Dr. Abubaker and just go down the line.
    Dr. Abubaker. Yes.
    Ms. Boss. Yes.
    Ms. Magermans. Yes.
    Secretary Tilley. Additional--and I apologize. I have to 
ask a question to clarify something. Additional funding for 
addiction treatment? I'm sorry, I apologize.
    Senator Hassan. Treatment, prevention, and recovery. But do 
we need more funding on the front lines?
    Secretary Tilley. Yes.
    Senator Hassan. Thank you.
    To Director Magermans, I want to thank you for your 
leadership in helping us understand how PDMPs are really 
critical to combatting this epidemic. I just wanted to drill 
down a little bit. While states can benefit greatly from these 
electronic data bases, there continues to be some difficulty in 
ease of use and accessibility. PDMPs are only informative if 
prescribers actually utilize them.
    Do you believe that integrating PDMPs into electronic 
health records will promote better work flow for providers and 
increase the likelihood that they would use PDMPs?
    Ms. Magermans. The short answer there is absolutely, yes.
    Senator Hassan. Okay. Do you think substance use counselors 
and mental health providers who often work with patients 
experiencing substance misuse disorders on a longer-term basis 
should have access to PDMP data as well?
    Ms. Magermans. In Wisconsin, substance abuse counselors 
licensed by the Department of Safety and Professional Services 
can access the PDMP, and the feedback that we have received 
from them is that it is a very valuable tool. We have other 
social workers with a specialty in substance abuse disorder 
treatment who access it as well, and they also say that it is a 
very valuable tool. I would say yes.
    Senator Hassan. Okay, thank you.
    To Secretary Tilley, I appreciated your testimony about the 
coordination between law enforcement and public health 
officials in Kentucky. We know that this is an epidemic that 
knows no bureaucratic boundaries, and we need to ensure that we 
are breaking down the silos between different agencies and 
officials, silos that can prevent us from responding 
appropriately to the epidemic, something I focused on when I 
was Governor. In New Hampshire we're doing some really 
interesting work. It's called Safe Stations. Through that 
initiative, firefighters are available 24/7 at participating 
stations to help connect individuals in need of treatment or 
recovery services so that people struggling with addiction know 
about the resources available to support them on the road to 
recovery, and so that firefighters can help with what we call a 
warm handoff to peer support or treatment.
    I am very proud of our brave firefighters for all they do 
to strengthen public safety and public health, including really 
driving this important initiative.
    Could you talk a little bit more about the importance of 
ensuring that public safety officials are helping us address 
these public health issues and whether you think programs like 
Safe Stations can help us turn the tide?
    Secretary Tilley. Absolutely. First responders are critical 
in this because they're the boots on the ground, first to 
respond. Again, things like needle exchange programs make it 
five times more likely that they touch the people on the ground 
where they are, the harm reduction model, find them, get them 
into treatment. That's part of the untold story there.
    LEAD, the Law Enforcement Assisted Diversion, is to get 
those mentally ill and addicted into treatment rather than a 
prison cell or a jail cell. That's very critical. Again, our 
Governor, having a very good connection to New Hampshire, we 
know about Safe Stations, and that is a great program. We need 
to do more of that.
    I also cannot go without mentioning our Angel initiative. 
We have a very dynamic State Police Commissioner who has spent 
a lifetime at the DEA, and he understands the need to do this. 
That's why we've made such tremendous progress in a very short 
period of time. Again, the Angel initiative is anyone can come 
in with paraphernalia, addicted, throw down that in a police 
station setting and be connected to treatment that same day. We 
guarantee that treatment bed the same day, no criminalization 
of any kind.
    Senator Hassan. Thank you very much.
    Thank you, Mr. Chair.
    The Chairman. Thank you, Senator Hassan.
    Senator Sanders.
    Senator Sanders. Thank you, Mr. Chairman, for holding this 
important hearing, and let me thank all the guests for being 
here. A lot of questions, short period of time.
    Let me just begin by saying that in my small State of 
Vermont, we have lost 112 people last year as a result of 
opioid overdoses, and that is three times more than who died in 
2010. In 2015, Vermont had the fifth highest prevalence rate of 
heroin use in the country, and in 2016 heroin-related emergency 
room visits increased by nearly 20 percent. Even in a small, 
beautiful, rural state, we have an epidemic.
    OxyContin's manufacturer, Purdue Pharma, pled guilty and 
agreed to pay more than $600 million in fines in 2007 for 
misleading the public about the risks of OxyContin. But the 
drug continued to rack up blockbuster sales, generating more 
than $22 billion in profits over the last decade.
    Should the pharmaceutical industry and companies like 
Purdue be treated the same way as the tobacco industry was 
treated decades ago? The tobacco industry killed millions of 
people in this country, and they lied to the American people 
about the health impacts of their product. Purdue and other 
companies produced a product, forgot to tell doctors or the 
people that it was addictive, thousands of people have died and 
suffered as a result.
    Should we--brief answers--hold those companies responsible 
in the same way we held the tobacco industry?
    Dr. Abubaker? Brief answers, please, because I have other 
questions.
    Dr. Abubaker. Research and development for development of 
treatment for addictions and treatment for pain medication 
that's not addictive, at least on that level.
    Senator Sanders. Ms. Boss.
    Ms. Boss. I would agree with the doctor. I'm not sure I'm 
really qualified to answer that question but would want more 
information on what kind of accountability we'd be looking for.
    Senator Sanders. Ms. Magermans.
    Ms. Magermans. I'm not qualified to answer that question.
    Senator Sanders. Secretary Tilley.
    Secretary Tilley. I may not be qualified, but my answer is 
yes, unequivocally. Kentucky settled a lawsuit years ago--well, 
they settled it, but it began in 2007, which should have been a 
billion-dollar settlement, at minimum, for the devastation that 
was caused in Appalachia in particular. It was a $24 million 
agreement to settle that is now still sealed. We don't even 
know what has been said. A deposition of one of those lead 
figures in this at this point is still silenced.
    Senator Sanders. Mr. Chairman, I don't understand--and I 
agree with Secretary Tilley. I just don't understand how we 
allow a situation to continue where these companies make 
billions of dollars in profit who essentially lied to 
physicians, lied to the American people, and have caused an 
epidemic. We've got to deal with that.
    My next question is I think we all understand that we need 
additional resources for treatment, and I don't mean to be 
overly political here because I know that everybody--
Republican, Democrat, Independent--is deeply concerned about 
this crisis.
    Brief answer, maybe yes or no. I believe that if this tax 
bill passes in the near future, there will be brought to the 
floor of the House and the Senate a trillion-dollar cut in 
Medicaid. That was in the Republican budget.
    Question: What happens to your programs if a trillion 
dollars in Medicaid is cut? Very briefly.
    Dr. Abubaker. I'm not sure of the financial implications of 
this issue.
    Senator Sanders. Ms. Boss.
    Ms. Boss. It's a really simple answer. I think all of our 
efforts are disintegrated, honestly. Our access to treatment is 
foundational, and Medicaid supports access to treatment.
    Senator Sanders. Thank you.
    Ms. Magermans, a trillion-dollar cut?
    Ms. Magermans. The PDMP greatly benefits from federal 
financial support.
    Senator Sanders. Secretary Tilley.
    Secretary Tilley. Again, assuming a trillion-dollar cut, I 
understand if you took that away from Kentucky, let me say 
this. Again, I don't think access always equals outcomes. I do 
have a real concern. We need money. We need it to come in other 
targeted ways, whether it comes to us--I'm not concerned about 
how it comes to us, but it needs to come to us with very 
targeted, surgical--if those are strings, so be it.
    Senator Sanders. If your Medicaid funding is cut, it's 
going to make your life a lot more difficult, will it not?
    Secretary Tilley. Well, I think if we don't have money to 
do the things we do today, there will be some challenges, 
although we are fighting for waivers to maintain those levels 
of funding.
    Senator Sanders. Okay, last question. At the end of the 
day, I think we are all in agreement that we have to do a 
better job of prevention in a wide variety of things. Are we 
doing as good a job--and I had a town meeting at the largest 
high school in the State of Vermont on this issue. Are we doing 
as good a job as we can reaching out to the young people and 
explaining to them the dangers, that just beginning to dabble 
in this issue of opioids can be a life-threatening decision? Do 
we do a good enough job, Secretary Tilley, in reaching out to 
the young people?
    Secretary Tilley. No, sir. We are doing everything we can 
at the moment, but we need to do twice that, and I think we 
need to reach to even a younger age and talk to them like we're 
talking today. Again, don't patronize young people, but we need 
to tell them exactly what can happen and how dangerous these 
things are.
    Senator Sanders. Ms. Magermans, young people?
    Ms. Magermans. I would definitely agree with his remarks.
    Senator Sanders. Ms. Boss.
    Ms. Boss. We have not, but a lot of our efforts that are 
funded now for the Cures and the other federal legislation that 
has passed are focusing on just that, and we're really trying 
to up our game in that area.
    Senator Sanders. Good.
    Dr. Abubaker.
    Dr. Abubaker. Senator, I said that in my opening statement, 
education, and I meant education all the way from middle school 
to medical school.
    Senator Sanders. Thank you all. Thank you very much.
    The Chairman. Thank you, Senator Sanders.
    Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman.
    While the opioid epidemic continues to ravage the country 
and my home State of Wisconsin, I have to say that I am proud 
that Wisconsin is leading in a number of respects, including an 
aggressive and innovative advancement like our state-of-the-art 
Wisconsin Enhanced Prescription Drug Monitoring Program. We 
have also implemented provider education requirements based on 
the CDC Opioid Prescribing Guideline, as well as many other 
reforms.
    Before getting into a couple of specific questions about 
that, I also want to associate myself with some of the previous 
comments of my colleagues regarding the need for additional 
resources. Whether it's the recommendation that we declare this 
a national emergency, but whether that's just words or 
resources too, that matters. Also I want to associate myself 
with the observation that the matter that we are discussing on 
the Senate floor today and potentially over the next several 
days has an enormous impact on our ability to fight this 
epidemic.
    But, Ms. Magermans, as we've heard time and again in this 
hearing, too often addiction begins with a legal prescription, 
whether that's for a broken leg or other injury, chronic back 
pain, oral surgery as we've been discussing, or it occurs 
because of a doctor or nurse who recklessly over-prescribes 
dangerous combinations of drugs, which happened actually at a 
VA facility in Wisconsin in Tomah.
    We need to have the real-time data about prescribing 
practices not only to arm doctors with the tools they need to 
care for the patients but also to ensure accountability for 
those dangerous outliers.
    I'd like you to elaborate a little bit further than you did 
with Senator Cassidy about how the Wisconsin ePDMP enhances 
provider education on safe prescribing, including with the CDC 
guidelines, and also how it acts as an oversight tool that can 
help manage over-prescribing.
    Ms. Magermans. Sure, thank you. The alerts that are made 
about patients and their prescription history are based on 
criteria that come from the CDC guidelines, so having to do 
with high levels of opioids or opioid/benzodiazepine overlap. 
The alerts have information in them so that they are also an 
education piece provided to the prescriber.
    The chart that shows the opioid level of the patient and 
whether or not there is an opioid/benzodiazepine overlap also 
has information about why that is presented to the prescribers, 
so the prescriber knows that there is a greater risk of 
overdose with the concurrent prescription or a high level of 
opioids. The benchmark lines at 50MME and 90MME come directly 
from CDC recommendations, and then there are links within the 
patient prescription history to report to the CDC for more 
information.
    Then within the prescribing practice metrics report for a 
prescriber there is an additional education piece that just 
explains some of the CDC guidelines, and that is one of the 
oversight tools that a prescriber can use to do a self-
assessment to see how that prescriber compares to others in the 
same specialty. Then a medical coordinator can also use that 
same report to look for outliers within a specific health 
system and provide education to the provider who might need 
some education.
    Senator Baldwin. Great. Just to clarify that last point, in 
response to Senator Cassidy you were talking about the 
potential of reporting your oversight with the Controlled 
Substances Board and their ability to communicate with 
licensing boards.
    Ms. Magermans. Yes, this is correct. Data coming from the 
PDMP is provided to the Controlled Substances Board. The 
Controlled Substances Board will determine whether or not a 
prescriber should be referred to the prescribing board for 
potential discipline.
    Senator Baldwin. I know we're watching the clock carefully, 
but I did reference the misuse of opioids at a VA facility in 
Wisconsin. It resulted in the tragic death of a Marine, and 
working with his family we introduced bipartisan legislation 
named in his honor, the Jason Simcakoski Memorial PROMISE Act. 
Senator Capito and I worked together on that.
    I guess my quick question for you is how is the Wisconsin 
PDMP interacting with and sharing data with the VA, and are VA 
providers submitting their prescription data?
    Ms. Magermans. Yes, VA clinics in Wisconsin are submitting 
dispensing data to the PDMP and have been for several years, 
even before it was required of them. Then on the other end, 
prescribers and other health care professionals in the VA 
system can use the PDMP as a tool to help inform their 
prescribing and dispensing decisions.
    The Chairman. Thank you, Senator Baldwin.
    Senator Murray.
    Senator Murray. Mr. Chairman, I'm going to submit my 
questions for the record. I just want to thank all of my 
colleagues. Many of my questions were answered, but this has 
been very helpful to us.
    I would just reiterate that having the resources seems to 
me a critical part of this discussion we can't leave out. But 
thank you very much to all of you.
    The Chairman. Thank you, Senator Murray.
    Senator Whitehouse.
    Senator Whitehouse. Thanks, Chairman. Thank you to the 
panel, particularly Ms. Boss.
    I'd like to get some advice from all of you. We've done the 
CARA bill, which I think was a very comprehensive and thorough 
piece of authorizing legislation, and we have the first half-
billion of the billion that we've been promised that has been 
pushed out, in addition to the regular funding. I assume it 
goes without saying that meeting our commitment to get you the 
second half-billion this December in the funding bill would be 
very important to the success of your efforts. Correct across 
the board?
    Ms. Magermans. Yes.
    Senator Whitehouse. Yes. You're counting on it?
    Ms. Boss. Yes.
    Senator Whitehouse. One of the things that the CARA bill 
required was better coordination among PDMPs. In different 
states they didn't talk to each other, they distributed 
information to different groups, the whole thing was a mess, 
and we've tried to encourage that it be consolidated and 
coordinated.
    Ms. Magermans, what is your advice to us in terms of 
getting a response from your peer group around the 50 states as 
to what we should be doing and what we should be seeing? 
Obviously, some may be laggards and they may not want to 
participate in encouraging certain things. But if it were 
possible for you and your colleagues or a majority of them to 
come up with some recommendations to keep this moving forward, 
I think that would be helpful. We're not seeing as much action 
as I would like on this out of the Administration.
    Do you think that's something that you would be capable of 
doing, the group of government officials that oversee PDMPs? Or 
is that asking too much?
    Ms. Magermans. I think PDMP administrators would greatly 
benefit from working together to learn from each other and to 
implement best practices based on others? experiences.
    Senator Whitehouse. Okay. Well, I will take advantage of 
that and try to figure out if I can get access to your network 
and start asking questions about where we should be right now, 
because wherever we should be right now, I know we're not 
there, and this is going to be worth some effort.
    Ms. Boss, one of the things that Rhode Island has done that 
is most novel has been to get those peer recovery coaches into 
the emergency departments so that when somebody comes in 
overdosed, they get a real opportunity for engagement before 
they get put back out on the street again. In that context, I 
have heard in a couple of places that the program bumps up 
against privacy protections of the patient, and I wonder if 
there are any lessons that we should take away from that 
experience in terms of considering whether there should be 
various types of exemptions from HIPAA, or whether there are 
good workarounds to HIPAA.
    As you know better than anyone, we had a terrible, terrible 
tragedy with an adult son of parents who was heavily addicted 
and had been in and out of the emergency department over and 
over again, and by the time he finally died of an overdose, his 
parents had never been notified of this recurring problem. I 
think in every state there is a story to that effect.
    To me, that's a bureaucratic failure. To me, we need to 
find a way to get through that so that the parents, the loved 
ones can be engaged, or if there's a complete breakdown of that 
relationship that perhaps some kind of a special master or 
something could be engaged.
    But tell us about what the privacy problems are with the ED 
program.
    Ms. Boss. I think two different problems related to this. 
One would be the fact that hospitals are not able to contact 
family members without the express permission of the individual 
in their care, and that would be a HIPAA violation if they did. 
One of the workarounds that we're looking at is using our 
health information exchange to get prior approval from 
individuals before they hit the emergency room of who can be 
contacted in an emergency, so at a moment when they're not in 
the midst of, perhaps, active addiction, identifying, yes, you 
can contact my whomever, and then being able to use that 
through our health information exchange that the emergency 
rooms have access to.
    Senator Whitehouse. That would be something set up by folks 
between their primary care provider and themselves early on, as 
a matter of regular doctor visits.
    Ms. Boss. Correct. The second is the ability to contact the 
peers if the individual in that moment at the emergency room is 
saying, no, I don't want to talk to a peer. One of the 
workarounds that we've done is create a special authorization 
that says you may not want to talk to a peer right now, you're 
in withdrawal, you're not feeling well, you're embarrassed, but 
can you sign this release and maybe they can contact you a day 
or two from now.
    We're piloting that right now and we are seeing significant 
increases in the connections with peers. Because they're not 
employees of the hospital, you need permission to contact them. 
That release has been a workaround that looks, as a pilot, like 
it's going to be pretty successful in engaging peers post the 
emergency department.
    Senator Whitehouse. My time is up, so I won't ask any more 
questions, but I would invite anybody else who wishes to 
respond to that question of the ED and the privacy issues to do 
a response for the record. You'll be asked questions for the 
record, and if you could add that to your questions for the 
record, and if there's anything else.
    I think this would be a very sensible place for us to do, 
Mr. Chairman, a little bit more work as a Committee.
    Thank you very much to the terrific panel.
    The Chairman. Thank you, Senator Whitehouse.
    I would say to the witnesses I have to leave, but Senator 
Franken has agreed to chair the remainder of the hearing. We 
have votes in a few minutes, so it won't be long. We have 
Senator Casey, and we have Senator Warren, both of whom are 
here. He'll call on them in that order for their 5 minutes of 
questioning.
    Let me thank each of you for very helpful testimony. I 
think you can tell from the attendance here and the careful 
questioning that we're very interested in learning from you 
what we can do to help.
    Senator Casey, why don't you go ahead? Senator Franken, 
thank you for chairing the remainder of the hearing.
    Senator Casey. Mr. Chairman, thank you very much.
    I first want to ask unanimous consent that a statement from 
the First Focus Campaign for Children, a statement for the 
record, be included in the hearing record for today.
    Senator Franken. [presiding] Without objection.
    Senator Casey. Thank you.
    I want to thank the panel members for your testimony and 
for the work you do on this problem. I'm not sure any of us 
have encountered a problem of this severity, and the 
professionals in the room would know better than I. But we're 
particularly grateful for your work and for your testimony 
today.
    I wanted to start with the question of funding. We've made, 
I think, good progress coming together, Democrats and 
Republicans, to recognize that this problem is so severe and so 
substantial that we've got to work together. We did that with 
the Comprehensive Addiction Recovery Act. We did that as well 
when we added dollars in the Cures Act at the end of last year. 
But we're still woefully short in terms of federal investment. 
That's why I recently introduced Senate bill 2004, the so-
called Combatting the Opioid Epidemic Act. This bill would set 
aside $45 billion over the next decade to address the epidemic, 
and the lion's share of that, of course, would go to the 
states.
    If I can ask you this, if you can speak to your own state, 
your own assessment of what would happen, what additional 
actions might your state take if you had more federal funding 
for this epidemic. I'll focus particularly on Ms. Boss and 
Secretary Tilley, but anyone else who wants to comment on it is 
certainly free to do that.
    Ms. Boss. I thank you for that, and I was hoping to get a 
question like this. Rhode Island's response has been pretty 
comprehensive, but we know that there's more that we can do if 
we had better access.
    Some of the things that I would touch upon have been 
mentioned before: pre-arrest diversion programs, very 
important, keeping people out of the criminal justice system; 
getting them access to treatment; rapid access through crisis 
centers, Safe Stations were mentioned, things like that are 
going to give rapid entry points to individuals to the 
treatment that they need; affordable naloxone is something that 
we're all concerned about, making sure that individuals can get 
Narcan that need Narcan; women-specific treatment, PPW 
programs. I know that CARA was looking at the importance of the 
PPW programs.
    Increasing funding for peers; effective prevention 
campaigns. I think that the need for effective prevention and 
reaching beyond just the opioid crisis has been mentioned 
several times, but prevention, engaging families, youth, and 
increasing the education to effective media campaigns.
    Research, we need research. We're not there yet. There's 
not a cure, and so we need better research. Finally, workforce 
development. We won't put a dent in this unless we have a 
workforce that's going to be able to address the need.
    Thank you for that question.
    Senator Casey. Thanks very much.
    Secretary Tilley.
    Secretary Tilley. Let me just reiterate, I concur with 
everything Rebecca said and just would add a couple of things. 
Take neonatal abstinence syndrome, for instance, any way you 
cut it, its impact on the Medicaid budget, any way you cut it, 
it's about a 10-to-1 return on investment. That's to the 
taxpayer, not to mention easing the suffering of an infant. 
Without that kind of funding--we had 1,300 babies born 
addicted. We have hospitals working day and night to prevent 
that kind of suffering. That would be the first and foremost 
thing I would say.
    I would also say that I do believe that you're working 
together and locking arms on this. Senator McConnell called us 
directly after the passage of CARE. We had a meeting in the 
rural part of our state for 2 hours, and he listened in ways 
that--to your question, how we could fund this. I am anxious 
for the funding as well.
    I do believe one thing that Rebecca would agree but did not 
mention. One of the pillars of care is also law enforcement, 
interdiction, the right kind. Again, in Kentucky we think we're 
doing that with LEAD. We're also using the Justice Center's 
Stepping Up model, the CSU Justice Center's Stepping Up model 
to get the mentally ill out of jails and prisons and into 
treatment, into the resources they need. We need that kind of 
funding. In interdiction, we've got to cutoff the supply.
    We need everything. We need prevention and treatment, 
absolutely. We also need the right kind of interdiction, not 
rounding up peddlers and addicts but actually cutting off the 
head of the snake here and drying the supply up. Part of that 
is the opioids, not just the heroin and fentanyl that's coming 
in and being illegally manufactured in China and other places 
across the globe. That has to stop. Our borders cannot allow 
that to flow in like it is today. I would add that to it.
    I'd simply say I'd be remiss if I didn't mention the long-
time efforts, too, of a group called UNITE in Kentucky, 
established by my Chairman Emeritus, Hal Rogers, that you all 
know well. We've been at this for so long in Kentucky that it 
feels good to have so much attention paid to this. It doesn't 
feel good in any way, but it's reassuring, so thank you for 
your help.
    Senator Casey. Thanks. I'll just end because I'm out of 
time. But on the research question, the intent of the bill, 
Senate bill 2004, is to dedicate about $250 million to that. On 
neonatal abstinence, actually Senator McConnell and I already 
passed a bill last year----
    Secretary Tilley. Yes, sir.
    Senator Casey----that directs HHS to focus on that issue.
    Thank you very much, Mr. Chairman.
    Senator Franken. Senator Baldwin.
    I'm sorry. Elizabeth, Senator Warren.
    Senator Warren. That's all right. Thank you, Mr. Chair.
    I've talked with people all over Massachusetts who are on 
the front lines in the opioid epidemic, and my staff and I also 
conducted a statewide survey, and I'll just give you some of 
the samples of what we heard.
    At the High Point Treatment Center in Plymouth, 
Massachusetts, the addiction, treatment, and recovery service 
providers talked about the challenges they face in recruiting 
and retaining enough treatment professionals. At the Salem Fire 
Department, the first responders explained how they're saving 
lives by expanding the use of overdose reversal medications. At 
nearly every town hall, from Barnstable to Lowell to 
Springfield, people shared stories about family members and 
friends who have died or who continue to grapple with 
addiction. In many of our communities, police officers have 
focused on redirecting those with addiction away from 
incarceration and into treatment by working hand in hand with 
health care providers.
    Secretary Tilley, I want to follow-up on that last point 
and on the work you've already engaged in. I know you've done a 
lot of work in Kentucky around criminal justice reform and 
improving access to addiction treatment. Can you just say a 
word about how important it is to have programs that get low-
level drug offenders into treatment and support services 
instead of into prison?
    Secretary Tilley. It's one of, if not the most important 
thing we can do in criminal justice and in public health as it 
relates to this addiction nightmare we're in.
    Senator Warren. In both.
    Secretary Tilley. In both, for so many reasons, because 
there's only so much of our tax base that can be dedicated 
anywhere in this state, in our state, or in the country at the 
moment, and when you siphon off and cutoff the ability, because 
of your corrections population or this incredible crush on your 
core system or law enforcement, again you cutoff your ability 
to attack it in the right ways.
    Then I would also say that you actually make the problem 
worse by incarcerating those who need treatment. It's 
criminogenic. You cutoff hope. You make it more difficult for 
them to get jobs with a felony on their record. We're working 
on reentry every day. The country is waking up to the fact that 
we have to give people that second and third chance at 
opportunity when they have criminal records. Seventy million 
Americans, because of this epidemic, in my mind, now have a 
criminal record in this country, one out of every three adults.
    I could take the next 2 minutes and 25 seconds to detail 
each and every impact it's had on our system.
    We have the highest percentage of children in Kentucky who 
have had or have an incarcerated parent. We have 8,500 kids 
today in foster care. If we could treat those in settings where 
they could keep their children--and that can occur, by the 
way--rather than having this incredible rate of per-capita 
incarceration for women--by the way, this country, out of every 
three women incarcerated in the world, one is here in the 
United States, and Kentucky is not doing much better than that 
as a state. We're working on that.
    Senator Warren. Let me ask you, though, in following up on 
this, I know that you mentioned earlier the LEAD program, the 
Law Enforcement Assisted Diversion program from Senator 
Murray's home state. We have a similar program in Massachusetts 
that we began with the Police Assisted Addiction Recovery 
Initiative, which was founded in Gloucester, Massachusetts. But 
the LEAD program allows police officers to redirect low-level 
drug offenders into community-based services instead of 
charging them with a drug offense. As you point out, it saves 
lives, saves money.
    I just want to ask you, if you could, just underline for a 
minute here, we talk often when we're talking about addiction 
and how to fight back, we talk about the role of doctors, we 
talk about the role of hospitals in doing this, but we rarely 
talk about the role of supporting our police and the importance 
of supporting our police in this, and I just wonder--we have 
just a little tiny bit of time left. Could I ask you, Secretary 
Tilley, to say a word about that?
    Secretary Tilley. Absolutely. We have law enforcement 
officers that, again, work within our cabinet in one sense or 
another. By the way, thank you for the Angel Initiative, 
Massachusetts. We mentioned that earlier. Kentucky became the 
first to mimic that and is working well with our State Police 
posts.
    Having said that, police, again front line soldiers in this 
regard, are overwhelmed, and they need more tools. Often times 
I have chiefs tell me that they need more social workers, 
frankly, in their departments to work with their officers, and 
the officers themselves tell me they need more social work 
capacity. We are training in things like crisis intervention, 
de-escalation. That yields tremendous results.
    I would point you to, quickly, the Data-Driven Justice 
Initiative. It's now in the Arnold Foundation, law enforcement 
assisted diversion we are using now which began in Seattle, 
again Stepping Up, and all manner of ways to allow first 
responders to be trained in how to meet people in these 
situations and divert them away from what is a crush on local 
jails, not to mention state prisons. Again, I think the 
redirection of these offenders is one of the most important 
things we could talk about today.
    Senator Warren. I really do appreciate that and couldn't 
agree more with your point. I led a number of my colleagues in 
calling for more funding to support LEAD and other diversion 
programs like it. Communities and police departments need every 
dollar they can get to be able to wage this battle.
    When I talk to people in Massachusetts who are on the front 
lines in this epidemic, one thing that's clear to me is that 
President Trump's promises to treat the epidemic as a public 
health emergency won't get the job done unless there are also 
significant increases in federal funding to support them. Our 
patients and our families deserve this.
    Thank you.
    Thank you, Mr. Chairman.
    Senator Franken. Thank you, Senator Warren.
    This whole area of criminal justice in the 21st Century 
Cures Act was proud to pass the Comprehensive Justice and 
Mental Health Act, which is about coordinating the criminal 
justice system and not incarcerating people who have addiction 
or mental health issues. I'm going to submit questions for the 
record on housing and doing that kind of coordinated care where 
you get facilitators to work with people who--very similar to 
what, Ms. Boss, you're doing in Rhode Island.
    Thank you all.
    The hearing record will remain open for 10 days. Members 
may submit additional information for the record within that 
time if they would like.
    The HELP Committee will meet again on Tuesday, December 
5th, at 10 a.m. for a hearing on Department of Education and 
Department of Labor nominations.
    Thank you for being here again today. Thank you all for the 
work that you do day in and day out.
    The Committee will stand adjourned.

    [Whereupon, at 12:15 p.m., the hearing was adjourned.]

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